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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.pdf
June 02, 2025 - PSI 03 Pressure Ulcer
PSI 06 Iatrogenic
Pneumothorax
PSI 07 Central Venous
Catheter-Related
Bloodstream … Rate on scale of 10 (agree/high) to 0 (disagree/low)
PDI 12 Central … Venous
Catheter-Related Blood
Stream Infection Rate
PDI 03 Retained
Surgical Item or
Unretrieved
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs022086-carayon-final-report-2019.pdf
January 01, 2019 - Health IT-Supported Process for Preventing and Managing Venous Thromboembolism (VTE) - Final Report … Final Report to AHRQ for Project on:
“Health IT-Supported Process for Preventing and Managing Venous … hospital with a Level 1 Trauma Center and serves as the
main tertiary and quaternary care center for Central … Role Network Analysis of Venous Thromboembolism (VTE) Diagnosis in the Emergency
Department. … Communication Strategies for Venous Thromboembolism Prophylaxis.
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www.ahrq.gov/hai/pfp/interimhac2013-ap2.html
December 01, 2014 - Catheter-Associated Urinary Tract Infections
400,000
290,000
110,000
28%
$110,000,000
2,563
Central … Ventilator-Associated Pneumonias
38,000
37,000
1,000
3%
$21,000,000
144
(Post-op) Venous
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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - At that time, he still had a central venous catheter in place, despite the antibiotic course having been … The patient had no signs or symptoms of infection and his central line was removed without complications … The patient also lacked follow-up with an Infectious Diseases physician and the central venous access … necessary laboratory tests, timely follow-up in the Infectious Diseases clinic would have occurred, and the central … venous catheter would have been removed at completion of therapy.
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www.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
June 01, 2025 - General Clinical Topics Infection Control: Carbapenem-Resistant Enterobacteriaceae Infection Control: Central … Hospitalized or Institutionalized Elders Sepsis Recognition Surgery, Anesthesia, and Perioperative Medicine Venous … Dedicated Staff (Not reviewed) (Not reviewed) Summary of Evidence (Not reviewed) Infection Control: Central … Room Integration and Display Systems (Not reviewed) Summary of Evidence (Not reviewed) (Not reviewed) Venous … Thromboembolism Patient Safety Practices MHS I (2001) MHS II (2013) MHS III (2020) MHS IV (2023-24) Prevention of Venous
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psnet.ahrq.gov/web-mm/ebola-are-we-ready
July 01, 2012 - The intensive care unit (ICU) physicians decided the patient needed central venous access and requested … Unfamiliar with the central line kit, they struggled but successfully put a triple-lumen catheter in … Sterile technique was breached multiple times as they navigated the central line insertion process in … The physician, who breached sterile technique during the central venous catheter (CVC) insertion, put … Simulation-based mastery learning reduces complications during central venous catheter insertion in a
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psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-safety
November 27, 2018 - for heart attacks, pneumonia, surgical care, children's asthma care, inpatient psychiatric services, venous … November 27, 2018
Preventing Central Line–Associated Bloodstream Infections: a Global
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psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-safety-2013
February 25, 2013 - for heart attacks, pneumonia, surgical care, children's asthma care, inpatient psychiatric services, venous … December 4, 2019
Preventing Central Line–Associated Bloodstream Infections: a Global
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c2_pdi_prioritizationworksheetexample.xlsx
June 02, 2025 - PDI 11 Postoperative Wound Dehiscence Rate 0.0 1.1 0 $76,737 $ - 0 N 5 5 5 Y Y Y Y Y
PDI 12 Central … Venous Catheter-Related Blood Stream Infection 0.4 0.8 2 $121,010 $ 242,020 N 10 9 9 Y Y Y Y N
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psnet.ahrq.gov/issue/patient-hand-initiation-and-evaluation-phone-study-randomized-trial-patient-handoff-methods
December 20, 2023 - Embracing errors in simulation-based training: the effect of error training on retention and transfer of central … venous catheter skills.
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psnet.ahrq.gov/issue/hand-hygiene-putting-nonsterile-gloves-intensive-care-unit-waste-health-care-worker-time
November 30, 2016 - November 30, 2016
Successful implementation of a unit-based quality nurse to reduce central … June 17, 2014
Eliminating central line-associated bloodstream infections: a national … , 2010
Minimizing errors of omission: Behavioural rEenforcement of Heparin to Avert Venous
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psnet.ahrq.gov/issue/testing-and-labeling-medical-devices-safety-magnetic-resonance-mr-environment
March 12, 2019 - Safety and Quality
April 26, 2023
Safety Risk of Air Embolus Associated with Central … Venous Catheters Used for Haemodialysis Treatment.
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psnet.ahrq.gov/issue/use-high-fidelity-simulation-enhance-interdisciplinary-collaboration-and-reduce-patient-falls
September 23, 2020 - Embracing errors in simulation-based training: the effect of error training on retention and transfer of central … venous catheter skills.
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psnet.ahrq.gov/issue/whats-sound-managing-alarm-fatigue
April 26, 2023 - 22, 2020
'Matching Michigan': a 2-year stepped interventional programme to minimise central … venous catheter-blood stream infections in intensive care units in England.
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psnet.ahrq.gov/issue/educational-and-audit-tool-reduce-prescribing-error-intensive-care
August 04, 2021 - June 8, 2011
Elimination of central-venous-catheter-related bloodstream infections from
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psnet.ahrq.gov/issue/morbidity-and-mortality-meeting-time-different-approach
August 30, 2023 - Preventing catheter-associated bloodstream infections: a survey of policies for insertion and care of central … venous catheters from hospitals in the Prevention Epicenter Program.
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psnet.ahrq.gov/issue/residency-program-fills-medication-safety-void
May 04, 2022 - RIS
Download Citation
Related Resources From the Same Author(s)
Central … venous catheter guidewire retention: lessons from England's never event database.
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psnet.ahrq.gov/issue/statewide-identification-adverse-events-using-retrospective-nurse-review-methods-and-outcomes
November 21, 2021 - September 27, 2016
Do clinicians know which of their patients have central venous catheters
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psnet.ahrq.gov/issue/how-safe-my-intensive-care-unit-overview-error-causation-and-prevention
November 25, 2020 - 30, 2010
'Matching Michigan': a 2-year stepped interventional programme to minimise central … venous catheter-blood stream infections in intensive care units in England.
-
psnet.ahrq.gov/issue/support-methods-healthcare-professionals-who-are-second-victims-integrative-review
April 27, 2022 - December 20, 2020
Simulation-based education enhances patient safety behaviors during central … venous catheter placement.