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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37425/psn-pdf
    March 28, 2012 - Frequency and outcome of cervical cancer prevention failures in the United States. March 28, 2012 Raab SS, Grzybicki DM, Zarbo RJ, et al. Frequency and outcome of cervical cancer prevention failures in the United States. Am J Clin Pathol. 2007;128(5):817-24. https://psnet.ahrq.gov/issue/frequency-and-outcome-cervi…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854384/psn-pdf
    January 01, 2024 - Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions. October 11, 2023 Ryan AN, Robertson KL, Glass BD. Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions. Int J Clin Ph…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45770/psn-pdf
    January 25, 2017 - Understanding patient-centred readmission factors: a multi-site, mixed-methods study. January 25, 2017 Greysen R, Harrison JD, Kripalani S, et al. Understanding patient-centred readmission factors: a multi-site, mixed-methods study. BMJ Qual Saf. 2017;26(1):33-41. doi:10.1136/bmjqs-2015-004570. https://psnet.ahrq.…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44746/psn-pdf
    January 20, 2016 - Creating a culture of safety around bar-code medication administration: an evidence-based evaluation framework. January 20, 2016 Kelly K, Harrington L, Matos P, et al. Creating a Culture of Safety Around Bar-Code Medication Administration: An Evidence-Based Evaluation Framework. J Nurs Adm. 2016;46(1):30-7. doi:10…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844550/psn-pdf
    September 01, 2012 - The effect of a Lean quality improvement implementation program on surgical pathology specimen accessioning and gross preparation error frequency. September 1, 2012 Smith ML, Wilkerson T, Grzybicki DM, et al. The effect of a Lean quality improvement implementation program on surgical pathology specimen accessionin…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60838/psn-pdf
    January 01, 2021 - Using the ecological systems theory to understand black/white disparities in maternal morbidity and mortality in the United States. August 26, 2020 Noursi S, Saluja B, Richey L. Using the ecological systems theory to understand black/white disparities in maternal morbidity and mortality in the United States. J Rac…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60734/psn-pdf
    July 29, 2020 - Delayed access to care and late presentations in children during the COVID-19 pandemic: a snapshot survey of 4075 paediatricians in the UK and Ireland. July 29, 2020 Lynn RM, Avis JL, Lenton S, et al. Delayed access to care and late presentations in children during the COVID-19 pandemic: a snapshot survey of 4075 …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38176/psn-pdf
    October 29, 2008 - Human error, not communication and systems, underlies surgical complications. October 29, 2008 Fabri PJ, Zayas-Castro JL. Human error, not communication and systems, underlies surgical complications. Surgery. 2008;144(4):557-63; discussion 563-5. doi:10.1016/j.surg.2008.06.011. https://psnet.ahrq.gov/issue/human-e…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849340/psn-pdf
    May 24, 2023 - Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities. May 24, 2023 Massachusetts Protection and Advocacy. Boston, MA:  Disability Law Center; May 8, 2023. https://psnet.ahrq.gov/issue/death-inside-lemuel-shattuck-hospital-case-study-medical-treat…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836959/psn-pdf
    April 20, 2022 - Safety of elderly fallers: identifying associated risk factors for 30-day unplanned readmissions using a clinical data warehouse. April 20, 2022 El Abd A, Schwab C, Clementz A, et al. Safety of elderly fallers: identifying associated risk factors for 30- day unplanned readmissions using a clinical data warehouse. …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35032/psn-pdf
    February 03, 2011 - Five years after 'To Err is Human': what have we learned? February 3, 2011 Leape L, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. 2005;293(19):2384-90. https://psnet.ahrq.gov/issue/five-years-after-err-human-what-have-we-learned Two of the leaders in the patient safety movement, Lucian …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866156/psn-pdf
    June 20, 2024 - Interventions to prevent falls in older adults: updated evidence report and systematic review for the US Preventive Services Task Force. June 20, 2024 Guirguis-Blake JM, Perdue LA, Coppola EL, et al. Interventions to prevent falls in older adults: updated evidence report and systematic review for the US Preventive…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47445/psn-pdf
    October 24, 2018 - Diagnostic error in the critically ill: defining the problem and exploring next steps to advance intensive care unit safety. October 24, 2018 Bergl PA, Nanchal RS, Singh H. Diagnostic Error in the Critically III: Defining the Problem and Exploring Next Steps to Advance Intensive Care Unit Safety. Ann Am Thorac Soc…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44237/psn-pdf
    November 03, 2015 - Surgical never events and contributing human factors. November 3, 2015 Thiels CA, Lal TM, Nienow JM, et al. Surgical never events and contributing human factors. Surgery. 2015;158(2):515-21. doi:10.1016/j.surg.2015.03.053. https://psnet.ahrq.gov/issue/surgical-never-events-and-contributing-human-factors Never even…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44203/psn-pdf
    August 04, 2015 - Variability in antibiotic use across nursing homes and the risk of antibiotic-related adverse outcomes for individual residents. August 4, 2015 Daneman N, Bronskill SE, Gruneir A, et al. Variability in Antibiotic Use Across Nursing Homes and the Risk of Antibiotic-Related Adverse Outcomes for Individual Residents.…

  16. Skin and Soft Tissue Infections in Nursing Home Residents (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/pocket-cards-4x6-skin-infections.pdf
    June 01, 2021 - Skin and Soft Tissue Infections in Nursing Home Residents Signs and Symptoms Associated With Infection • Sudden onset redness, warmth, tenderness, and swelling • Findings are unilateral • Presence of purulent drainage or abscess • Fever, tachycardia present Causes of Noninfectious Ski…

  17. Defects (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module2/defects.docx
    March 01, 2017 - AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Long-Term Care Safety Modules Learn From Defects Purpose: To identify the types of systems that contributed to the defect (an event or situation that you do not want to happen again) and to plan the followup steps needed to improve safety Who should use this too…

  18. Reportforcd Issueinmdsid2006-2009 (pdf file)

    hcup-us.ahrq.gov/db/state/siddist/ReportforCD_%20IssueinMDSID2006-2009.pdf
    January 01, 2009 - The Maryland HCUP State Inpatient Databases (SID) for 2006-2009 contain problems with the coding of discharge disposition (DISPuniform). Transfers to other acute care hospitals are misidentified as transfers to other health facilities. The source-provided patient disposition codes for the following were erroneou…

  19. Update on Methods: Insufficient Evidence - Table 3 | United States Preventive Services Taskforce

    www.uspreventiveservicestaskforce.org/uspstf/update-on-methods-insufficient-evidence---table-3
    February 01, 2009 - Update on Methods: Insufficient Evidence - Table 3 Share to Facebook Share to X Share to WhatsApp Share to Email Print Table 3. Application of the 4 Domains: Skin Cancer Screening Using Visual Inspection Domain Information Pot…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867752/psn-pdf
    March 12, 2025 - Analyzing and mitigating the risks of patient harm during operating room to intensive care unit patient handoffs. March 12, 2025 Martins NRS, Martinez EZ, Simões CM, et al. Analyzing and mitigating the risks of patient harm during operating room to intensive care unit patient handoffs. Int J Qual Health Care. 2025;…
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