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psnet.ahrq.gov/node/74101/psn-pdf
November 24, 2021 - Management of the deteriorating adult patient: does
simulation-based education improve patient safety?
November 24, 2021
Bennion J, Mansell SK. Management of the deteriorating adult patient: does simulation-based education
improve patient safety? Br J Hosp Med (Lond). 2021;82(8):1-8. doi:10.12968/hmed.2021.0293.
h…
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psnet.ahrq.gov/node/36947/psn-pdf
September 09, 2011 - The safety of warfarin therapy in the nursing home
setting.
September 9, 2011
Gurwitz JH, Field T, Radford MJ, et al. The safety of warfarin therapy in the nursing home setting. Am J
Med. 2007;120(6):539-44.
https://psnet.ahrq.gov/issue/safety-warfarin-therapy-nursing-home-setting
The anticoagulant warfarin is co…
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psnet.ahrq.gov/node/843326/psn-pdf
February 01, 2023 - Surgical site infection prevention: a review.
February 1, 2023
Seidelman JL, Mantyh CR, Anderson DJ. Surgical site infection prevention: a review. JAMA.
2023;329(3):244-252. doi:10.1001/jama.2022.24075.
https://psnet.ahrq.gov/issue/surgical-site-infection-prevention-review
Surgical site infections (SSIs) remain a …
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psnet.ahrq.gov/node/50429/psn-pdf
September 04, 2019 - Is disruptive behavior inherent to the surgeon or the
environment? Analysis of 314 events at a single academic
medical center.
September 4, 2019
Heslin MJ, Singletary BA, Benos KC, et al. Is Disruptive Behavior Inherent to the Surgeon or the
Environment? Analysis of 314 Events at a Single Academic Medical Center. …
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psnet.ahrq.gov/node/46891/psn-pdf
December 21, 2018 - Day of discharge does not impact hospital readmission
after major cardiac surgery.
December 21, 2018
Sanaiha Y, Ou R, Ramos G, et al. Day of Discharge Does Not Impact Hospital Readmission After Major
Cardiac Surgery. Ann Thorac Surg. 2018;106(6):1767-1773. doi:10.1016/j.athoracsur.2018.07.031.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/37790/psn-pdf
April 11, 2011 - Adolescent use of insulin and patient-controlled
analgesia pump technology: a 10-year Food and Drug
Administration retrospective study of adverse events.
April 11, 2011
Cope JU, Morrison AE, Samuels-Reid J. Adolescent use of insulin and patient-controlled analgesia pump
technology: a 10-year Food and Drug Administ…
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psnet.ahrq.gov/node/848816/psn-pdf
May 10, 2023 - Racial bias in cesarean decision-making.
May 10, 2023
Edwards SE, Class QA, Ford CE, et al. Racial bias in cesarean decision-making. Am J Obstet Gynecol
MFM. 2023;5(5):100927. doi:10.1016/j.ajogmf.2023.100927.
https://psnet.ahrq.gov/issue/racial-bias-cesarean-decision-making
Racial bias negatively impacts maternal…
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psnet.ahrq.gov/node/47651/psn-pdf
December 12, 2018 - Are national efforts to reduce drug name confusion
paying off?
December 12, 2018
ISMP Medication Safety Alert! Acute Care Edition. November 29, 2018;23:1-6.
https://psnet.ahrq.gov/issue/are-national-efforts-reduce-drug-name-confusion-paying
Look-alike and sound-alike medications present a recurring threat to patie…
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psnet.ahrq.gov/node/44393/psn-pdf
August 12, 2015 - FDA Drug Safety Communication: FDA warns about
prescribing and dispensing errors resulting from brand
name confusion with antidepressant Brintellix
(vortioxetine) and antiplatelet Brilinta (ticagrelor).
August 12, 2015
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; July 30, 2015.
https…
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psnet.ahrq.gov/node/45280/psn-pdf
September 01, 2018 - Fighting MRSA infections in hospital care: how
organizational factors matter.
September 1, 2018
Salge TO, Vera A, Antons D, et al. Fighting MRSA Infections in Hospital Care: How Organizational Factors
Matter. Health Serv Res. 2016;52(3):959-983. doi:10.1111/1475-6773.12521.
https://psnet.ahrq.gov/issue/fighting-mr…
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psnet.ahrq.gov/node/72644/psn-pdf
February 01, 2021 - Best Practices in Developing Proprietary Names for
Human Nonprescription Drug Products.
January 13, 2021
Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for
Drug Evaluation and Research; December 7, 2020.
https://psnet.ahrq.gov/issue/best-practices-developing-p…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/poster-4x6-delirium.pdf
June 01, 2021 - Identifying Delirium: ABCs of Identification_4x6
AHRQ Pub. No. 17(21)-0029
June 2021
IDENTIFYING DELIRIUM
ABCs OF IDENTIFICATION
Acute/subacute
• Altered mental status from baseline
Behavioral disturbance
• Restless, agitated, combative
Changes in consciousness
• Jittery, drowsy, difficult to aro…
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www.ahrq.gov/pqmp/implementation-qi/toolkit/h2h/improvement-data.html
July 01, 2021 - Quality of Pediatric Hospital-to-Home Transitions Toolkit
Improvement Data
Previous Page Next Page
Table of Contents
Quality of Pediatric Hospital-to-Home Transitions Toolkit
Introduction
Overview
About the Measure
Key Driver Diagram
Quality Improvement Strategies
Improvement Data
Othe…
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hcup-us.ahrq.gov/db/state/siddist/Iowa2009_2010SID_CD.pdf
December 01, 2011 - The Iowa HCUP State Inpatient Databases (SID) for 2009 (dated June or August 2010)
and 2010 (dated September 2011) contain misleading discharge data from four hospitals
accounting for about 11 percent of the files. The affected discharge data include
incorrect reporting of the principal procedure and incorrect orde…
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psnet.ahrq.gov/node/47670/psn-pdf
March 20, 2019 - Targeting the fear of safety reporting on a unit level.
March 20, 2019
Copeland D. Targeting the Fear of Safety Reporting on a Unit Level. J Nurs Adm. 2019;49(3):121-124.
doi:10.1097/NNA.0000000000000724.
https://psnet.ahrq.gov/issue/targeting-fear-safety-reporting-unit-level
Blame culture in health care settings …
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psnet.ahrq.gov/node/74084/psn-pdf
November 17, 2021 - Healthcare failure mode and effect analysis in the
chemotherapy preparation process.
November 17, 2021
Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. Healthcare failure mode and effect
analysis in the chemotherapy preparation process. J Oncol Pharm Pract. 2021;27(7):1588-1595.
doi:10.1177/107815522…
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psnet.ahrq.gov/node/47426/psn-pdf
October 13, 2018 - Patient-centered insights: using health care complaints to
reveal hot spots and blind spots in quality and safety.
October 13, 2018
Gillespie A, Reader TW. Patient-Centered Insights: Using Health Care Complaints to Reveal Hot Spots and
Blind Spots in Quality and Safety. Milbank Q. 2018;96(3):530-567. doi:10.1111/14…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apa_rsv.pdf
June 02, 2025 - NICU Toolkit, Appendix A, Respiratory Syncytial Virus (RSV)
Respiratory Syncytial Virus (RSV)
What is Respiratory
Syncytial Virus (RSV)?
■ A common virus that affects babies
and infants.
■ Leading cause of two lung
infections: pneumonia and
bronchitis.
Symptoms of RSV
■ Starts out like a cold with fever o…
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psnet.ahrq.gov/node/836836/psn-pdf
March 30, 2022 - Deficiencies after the New Electronic Health Record Go-
Live at the Mann-Grandstaff VA Medical Center in
Spokane, WA.
March 30, 2022
Washington, DC: VA Office of Inspector General; March 17, 2022.
https://psnet.ahrq.gov/issue/deficiencies-after-new-electronic-health-record-go-live-mann-grandstaff-va-
medical-cent…
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-c-screening-2013
June 15, 2013 - Share to Facebook
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Final Recommendation Statement
Hepatitis C: Screening
June 15, 2013
Recommendations made by the USPSTF are independent of the U.S. government. They should n…