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6981. Initiating Dialysis With Fistula or Graft: Accessing Medication Port To Administer Medication | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/esrd/resource/dialysis-fistula.html
      April 01, 2014 - Initiating Dialysis With Fistula or Graft: Accessing Medication Port To Administer Medication This video vignette illustrates proper initiation of dialysis for patients with fistulae or grafts and the way to properly administer medication. It can be shared with staff as a refresher on current practices and guid…

6982. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37305/psn-pdf
      January 02, 2011 - Medication administration in anesthesia: time for a paradigm shift. January 2, 2011 Stabile M; Webster CS; Merry AF. https://psnet.ahrq.gov/issue/medication-administration-anesthesia-time-paradigm-shift To reduce anesthesia administration errors, the authors propose changing the organizational culture to foster a…

6983. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35165/psn-pdf
      June 23, 2009 - Error reporting as a preventive force. June 23, 2009 Simpson RL. Error reporting as a preventive force. Nurs Manage. 2005;36(6):21-24, 56. https://psnet.ahrq.gov/issue/error-reporting-preventive-force This author highlights how error reporting can improve patient safety when supported by information technology, le…

6984. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35521/psn-pdf
      April 26, 2012 - Patient Safety Papers. April 26, 2012 Baker RG, ed. Healthc Q. 2005;8 Spec No:1-156. https://psnet.ahrq.gov/issue/patient-safety-papers This special issue highlights Canadian experiences in several safety-related areas: culture shift in support of safety, risk identification and reduction, medication safety, chang…

6985. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40280/psn-pdf
      June 10, 2018 - That’s the way we do things around here! June 10, 2018 ISMP Medication Safety Alert! Acute care edition. February 24, 2011;16:1-2. https://psnet.ahrq.gov/issue/thats-way-we-do-things-around-here This piece discusses the effects of personal behaviors and peer interactions on an organization’s safety culture. https…

6986. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37281/psn-pdf
      December 23, 2011 - Crime in the workplace, part 1. December 23, 2011 Pastorius D. Crime in the workplace, part 1. Nurs Manage. 2007;38(10):18, 20, 22, 24, 26-27. https://psnet.ahrq.gov/issue/crime-workplace-part-1 The author discusses the dynamic between blame and accountability within the context of the just culture paradigm. http…

6987. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38857/psn-pdf
      July 31, 2012 - Name and shame. July 31, 2012 Cassidy J. Name and shame. BMJ. 2009;339:b2693. doi:10.1136/bmj.b2693. https://psnet.ahrq.gov/issue/name-and-shame This article examines the impact of whistleblowing on the caregivers involved, using the Bristol incident and other high-profile examples from the United Kingdom. https:…

6988. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38230/psn-pdf
      August 11, 2010 - The Patient Safety Leadership WalkRounds Guide. August 11, 2010 Frankel AS, Grillo S, Pittman MA. Chicago, IL: Health Research and Educational Trust; 2006. https://psnet.ahrq.gov/issue/patient-safety-leadership-walkrounds-guide This booklet provides information on the implementation of a WalkRounds program as a cul…

6989. In Conversation with...Brent C. James, MD, MStat | PSNet
      psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
      February 26, 2025 - In Conversation with...Brent C. James, MD, MStat February 1, 2011  Citation Text: In Conversation with..Brent C. James, MD, MStat. PSNet [internet]. 2011.In Conversation with...Brent C. James, MD, MStat. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…

6990. Promising Areas for Patient Safety Research | PSNet
      psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
      November 02, 2016 - Promising Areas for Patient Safety Research P. Jeffrey Brady, MD, MPH; William B. Munier, MD, MBA; Irim Azam, MPH | December 1, 2003  View more articles from the same authors. Citation Text: Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. …

6991. Difficult Encounters: A CMO and CNO Respond | PSNet
      psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
      March 01, 2018 - SPOTLIGHT CASE Difficult Encounters: A CMO and CNO Respond Citation Text: Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: …

6992. Making Healthcare Safer IV Report Expanded With New Evidence Reviews | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsletters/e-newsletter/910.html
      April 01, 2024 - Making Healthcare Safer IV Report Expanded With New Evidence Reviews Issue Number 910 AHRQ News Now is a weekly newsletter that highlights agency research and program activities. April 23, 2024 AHRQ Stats: Dental Treat-and-Release Emergency Department Visits During the COVID-19 Era The number of treat…

6993. Diagnostic Stewardship Interventions To Reduce Diagnostic Error | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship5.html
      August 01, 2024 - Diagnostic Stewardship as a Model To Improve the Quality and Safety of Diagnosis Diagnostic Stewardship Interventions To Reduce Diagnostic Error Previous Page Next Page Table of Contents Diagnostic Stewardship as a Model To Improve the Quality and Safety of Diagnosis Introduction Background …

6994. Planning for Sustainability | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/guide-planning.html
      May 01, 2017 - Creating a Culture of Safety in the Ambulatory Surgery Environment: Implementation Guide Planning for Sustainability Previous Page Next Page Table of Contents Creating a Culture of Safety in the Ambulatory Surgery Environment: Implementation Guide Overview The Comprehensive Unit-based Safety Pro…

6995. Better Nurse Staffing Levels Associated With Lower Rates of Cesarean Section | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsletters/e-newsletter/945.html
      February 01, 2025 - Better Nurse Staffing Levels Associated With Lower Rates of Cesarean Section Issue Number 945 AHRQ News Now is a weekly newsletter that highlights agency research and program activities. February 11, 2025 AHRQ Stats: Rates of Central-Line Associated Bloodstream Infections by Hospital Type The rate of ce…

6996. Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care-2/index.html
      July 01, 2023 - Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage AHRQ Safety Program for Perinatal Care, Phase 2 Following the release of AHRQ’s Toolkit for Improving Perinatal Safety , a second bundle of AHRQ tools is available to improve the safety culture of labor and delivery (L&D) units. The second…

6997. Errors in Paramedic Endotracheal Intubation (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/2006Wang_051611comp.pdf
      January 01, 2006 - Errors in Paramedic Endotracheal Intubation Errors in Paramedic Endotracheal Intubation Henry E. Wang, MD, MPH Assistant Professor Department of Emergency Medicine University of Pittsburgh School of Medicine University of Pittsburgh School of Medicine - Department of Emergency Medicine Disclosures  AHRQ Cli…

6998. Section 2, Technical Specifications (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-232-tech-specs.pdf
      June 02, 2025 - Section 2, Technical Specifications 1 Sepsis Measure 6: Documentation of Heart Rate during Fluid Resuscitation in Children with Severe Sepsis or Septic Shock Description The proportion of hospitalized children with severe sepsis or septic shock who had documentation of heart rate at least every…

6999. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38666/psn-pdf
      June 27, 2018 - Leadership practices to advance patient safety. June 27, 2018 Crowley JD, Deen JB. Patient Saf Qual Healthc. May/June 2009;6:18-22. https://psnet.ahrq.gov/issue/leadership-practices-advance-patient-safety This article charts one health system's efforts to create a culture of safety through leadership development i…

7000. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37111/psn-pdf
      January 01, 2023 - Patient Safety: An Old and New Issue. August 22, 2007 Bagnara S; Tartaglia R, eds. Theor Issues Ergon Sci. 2023;8(5):365-507. https://psnet.ahrq.gov/issue/patient-safety-old-and-new-issue This special issue contains articles focusing on ergonomic research areas that intersect with patient safety, such as team mana…