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psnet.ahrq.gov/node/844558/psn-pdf
January 13, 2024 - On Patient Safety.
January 13, 2024
Tingle J. Br J Nurs. 2001-2024.
https://psnet.ahrq.gov/issue/patient-safety-19
This series of commentaries discusses a wide range of policy, legal, and operational topics related to
patient safety in the British health system, such as artificial intelligence, patient communicati…
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psnet.ahrq.gov/node/46151/psn-pdf
May 24, 2017 - The last person you'd expect to die in childbirth.
May 24, 2017
Martin N, Montagne R. ProPublica and National Public Radio. May 12, 2017.
https://psnet.ahrq.gov/issue/last-person-youd-expect-die-childbirth
Maternal mortality is increasing in the United States. This news article reports on this critical safety probl…
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psnet.ahrq.gov/node/74193/psn-pdf
December 15, 2021 - Input for the TeamSTEPPS Curriculum Updates.
December 15, 2021
Rockville MD, Agency for Healthcare Quality and Research. December 7, 2021.
https://psnet.ahrq.gov/issue/input-teamstepps-curriculum-updates
The TeamSTEPPS program is an established approach for improving teamwork and communication in
health care. This…
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psnet.ahrq.gov/node/42757/psn-pdf
November 20, 2013 - Clinical ICT Systems in the Victorian Public Health Sector.
November 20, 2013
Doyle J. Melbourne, Australia: Victorian Auditor-General's Office; October 30, 2013.
https://psnet.ahrq.gov/issue/clinical-ict-systems-victorian-public-health-sector
Following the implementation of a large clinical information communicati…
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psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - Lapse in Antibiotics Leads to Sepsis
October 1, 2016
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
The Case
A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal
pain, fevers, and short…
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psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - Is It Safe to Be Direct?
Citation Text:
Kulkarni NS, Williams M. Is It Safe to Be Direct?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/50843/psn-pdf
January 29, 2020 - Incomplete Orders for Hypertonic Saline to Treat
Hyponatremia
January 29, 2020
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet].
2020.
https://psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
The Case
A 54-year-old man was brought t…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/leveraging-cultural-change-080814.pptx
January 01, 2013 - Slide 1
Leveraging Cultural Change to Reduce Urinary Catheter Use
1
Linda Greene, RN,MPS,CIC
Manager Infection Prevention
Highland Hospital
Jennifer Tuttle, RN, MSNEd
Adult Critical Care Unit
Tucson Medical Center
Learning Objectives
Describe the way in which improvement in the clinical culture can facilitate e…
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psnet.ahrq.gov/node/49686/psn-pdf
May 01, 2013 - Don't Use That Port: Insert a PICC
May 1, 2013
Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
The Case
A 48-year-old woman receiving neoadjuvant therapy for breast cancer was admitted to the hospital with
fever and abdominal pain. A comp…
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psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
October 30, 2024 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates
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February 9, 2021
…
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psnet.ahrq.gov/node/853772/psn-pdf
September 27, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not
Interchangeable
September 27, 2023
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
The Case
A fourteen-ye…
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psnet.ahrq.gov/web-mm/wrong-route-nutrients
September 04, 2010 - Wrong Route for Nutrients
Citation Text:
Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/misleading-complaint
December 01, 2009 - Misleading Complaint
Citation Text:
Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Learning From Defects: Applying the “Swiss cheese model” of System Failure
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
Slide Title and Commentary
Slide Number and Slide
Learning From Defects: Applying the “Swiss C…
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psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
August 30, 2023 - Strategies to Improve Organizational Health Literacy.
Citation Text:
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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digital.ahrq.gov/ahrq-funded-projects/improving-population-health-through-enhanced-targeted-regional-decision-support
January 01, 2023 - Improving Population Health Through Enhanced Targeted Regional Decision Support
Project Final Report ( PDF , 1.05 MB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily repr…
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psnet.ahrq.gov/node/60167/psn-pdf
April 12, 2024 - Discharge Planning and Transitions of Care
March 25, 2020
Bajorek SA, McElroy V. Discharge Planning and Transitions of Care. PSNet [internet]. 2020.
https://psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
Background
Transitions of care refer to the movement of patients between different healthcare se…
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psnet.ahrq.gov/web-mm/not-miscarriage
June 01, 2005 - Not a Miscarriage
Citation Text:
Learman LA. Not a Miscarriage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/databases/hospital/2024-hospital-database-report-appendix.pdf
January 01, 2024 - Surveys on Patient Safety Culture (SOPS) Hospital 2.0 Survey: 2024 User Database Report Part II
Surveys on Patient Safety Culture® (SOPS®)
Hospital Survey 2.0:
2024 User Database Report
Part II: Appendix A—Results by Hospital Characteristics
Appendix B—Results by Respondent Characteristics
Prepared for:
Age…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2022-hsops2-database-report-appendixes.pdf
January 01, 2022 - Surveys on Patient Safety Culture (SOPS) Hospital 2.0 Survey: 2022 User Database Report Part II
Surveys on Patient Safety Culture™ (SOPS®)
Hospital Survey 2.0:
2022 User Database Report
Part II: Appendix A—Results by Hospital Characteristics
Appendix B—Results by Respondent Characteristics
Prepared for:
Agen…