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9721. Selected Best Practices and Suggestions for Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4b_combo_psi05-foreignbody-bestpractices.pdf
      November 01, 2012 - Selected Best Practices and Suggestions for Improvement Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety 1 Tool D.4b Selected Best Practices and Suggestions for Improvement PSI 05: Retained Surgical Item or Unretrieved Device Fragment Count Why Focus on Retained Fore…

9722. Selected Best Practices and Suggestions for Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4q_combo_pdi03-foreignbody-bestpractices.pdf
      November 01, 2012 - Selected Best Practices and Suggestions for Improvement Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety 1 Tool D.4q Selected Best Practices and Suggestions for Improvement PDI 03: Retained Surgical Item or Unretrieved Device Fragment Count Why focus on retained forei…

9723. Comparative Health System Performance Initiative: Compendium of U.S. Health Systems, 2016, Technical Documentation-Appendix D (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/techdocrpt-appd.pdf
      January 01, 2019 - Comparative Health System Performance Initiative: Compendium of U.S. Health Systems, 2016, Technical Documentation-Appendix D Comparative Health System Performance Initiative: Compendium of U.S. Health Systems, 2016, Technical Documentation Prepared for: Agency for Healthcare Research and Quality U.S. Depar…

9724. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49688/psn-pdf
      August 21, 2013 - Discharge Instructions in the PACU: Who Remembers? August 21, 2013 Engel KG. Discharge Instructions in the PACU: Who Remembers? PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers The Case A 42-year-old woman was diagnosed with a torn anterior cruciate ligament (ACL) in …

9725. Facapplycusp (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/facapplycusp.docx
      June 02, 2025 - SAY: The “Apply CUSP” module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit introduces Just Culture principles, which emphasize shared accountability and attitudes toward risk. This module also summarizes the concepts and activities of the other six modules in the CUSP Toolkit. Slide 1 SAY: In th…

9726. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33625/psn-pdf
      January 01, 2006 - Aviation Safety Methods: Quickly Adopted but Questions Remain January 1, 2006 Thomas EJ. Aviation Safety Methods: Quickly Adopted but Questions Remain. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain Perspective On August 2, 2005, Air France flig…

9727. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846125/psn-pdf
      March 15, 2023 - The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis March 15, 2023 https://psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels- and-effective Summary …

9728. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49731/psn-pdf
      April 01, 2015 - Fire in the Hole!—An OR Fire April 1, 2015 Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fire-hole-or-fire The Case A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection for a biopsy-proven adenocarcinom…

9729. Publications and Additional Materials | Agency for Healthcare Research and Quality
      www.ahrq.gov/pqmp/publications/search.html
      January 01, 2021 - All Publications The following list presents materials published as a result of the AHRQ-CMS Pediatric Quality Measures Program (PQMP). Results 1 - 25 of 107 Publications Pagination 1 2 3 4 5 next › ›› last » Last » Provider Specialty and R…

9730. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49835/psn-pdf
      January 01, 2020 - Don't Pick the PICC July 1, 2018 McGill RL. Don't Pick the PICC. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/dont-pick-picc The Case A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy; glaucoma; and stage IV chronic kidney disease was admitted to the hospita…

9731. Nursing Intervention to Remove Non-necessary Urinary Catheters
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/building-team-040814.pptx
      January 01, 2013 - Nursing Intervention to Remove Non-necessary Urinary Catheters Mohamad Fakih, MD, MPH Professor of Medicine Wayne State University School of Medicine Medical Director, Infection Prevention and Control St. John Hospital and Medical Center Barbara Lucas, MD, MHSA Project Consultant Michigan Health & Hospital Associatio…

9732. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49707/psn-pdf
      April 01, 2014 - CYP450 Drugs: Expect the Unexpected April 1, 2014 Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected The Case A 42-year-old man with acquired immunodeficiency syndrome (AIDS) (CD4 count 198), hip dystocia, and generalized anxiety …

9733. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49493/psn-pdf
      November 01, 2005 - Infused, Not Ingested November 1, 2005 Foley M. Infused, Not Ingested. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/infused-not-ingested The Case A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering contrast, an unfamiliar task for this particular nurse. Rathe…

9734. Toolkit Prelaunch Activities (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/introduction/prelaunch-activities.pdf
      March 01, 2022 - Toolkit Prelaunch Activities Decolonization of Non-ICU Patients With Devices Section 8 – Toolkit Prelaunch Activities We recommend that you follow the prelaunch checklist below (Table 8-1) for successful implementation. As is the case with many infection prevention programs, it will take time to achie…

9735. Assess Patient Safety Culture Using the Hospital Survey on Patient Safety: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/cusp/assess-psc-hsop-slides.html
      February 01, 2017 - Assess Patient Safety Culture Using the Hospital Survey on Patient Safety: Slide Presentation AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients Assess Patient Safety Culture Using the Hospital Survey on Patient Safety Slide 2: Lear…

9736. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49713/psn-pdf
      June 01, 2014 - CVC Removal: A Procedure Like Any Other June 1, 2014 Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other The Case A 27-year-old man with a history of Behçet disease and recurrent liver abscesses was admitted to the hospital for a p…

9737. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73335/psn-pdf
      May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition Error May 26, 2021 Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error The Case A 4-year-old (former 33-week premature) boy with a …

9738. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72693/psn-pdf
      January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules January 29, 2021 Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules The Case A…

9739. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49607/psn-pdf
      August 01, 2010 - Missed Patient Assignment: Is Anyone There? August 1, 2010 Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There? PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there The Case In one hospital, nurses' patient assignments were communicated by listing the…

9740. Final Progress Report: Parent Perceptions of NICU Safety Culture: Parent-Centered Safety Culture Tool (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/etchegaray2-report.pdf
      January 01, 2024 - Final Progress Report: Parent Perceptions of NICU Safety Culture: Parent-Centered Safety Culture Tool Parent Perceptions of NICU Safety Culture: Parent-Centered Safety Culture Tool Project Team: Jason M. Etchegaray, PhD (PI; RAND Corporation); Madelene J. Ottosen, PhD (The University of Texas Medical School at Hous…