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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/poster-4x6-delirium.pdfJune 01, 2021 - Identifying Delirium: ABCs of Identification_4x6 AHRQ Pub. No. 17(21)-0029 June 2021 IDENTIFYING DELIRIUM ABCs OF IDENTIFICATION Acute/subacute • Altered mental status from baseline Behavioral disturbance • Restless, agitated, combative Changes in consciousness • Jittery, drowsy, difficult to aro…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45412/psn-pdfNovember 18, 2016 - The multidisciplinary approach to GI cancer results in change of diagnosis and management of patients. Multidisciplinary care impacts diagnosis and management of patients. November 18, 2016 Meguid C, Schulick RD, Schefter TE, et al. The Multidisciplinary Approach to GI Cancer Results in Change of Diagnosis and Ma… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/34083/psn-pdfJune 30, 2011 - Handoff strategies in settings with high consequences for failure: lessons for health care operations. June 30, 2011 Patterson ES. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care. 2004;16(2):125-132. doi:10.1093/intqhc/mzh026. https://ps… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40220/psn-pdfMarch 21, 2012 - Incidence and preventability of adverse events requiring intensive care admission: a systematic review. March 21, 2012 Vlayen A, Verelst S, Bekkering GE, et al. Incidence and preventability of adverse events requiring intensive care admission: a systematic review. J Eval Clin Pract. 2012;18(2):485-97. doi:10.1111/j… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/838185/psn-pdfSeptember 28, 2022 - How to mitigate the effects of cognitive biases during patient safety incident investigations. September 28, 2022 Rogers JE, Hilgers TR, Keebler JR, et al. How to mitigate the effects of cognitive biases during patient safety incident investigations. Jt Comm J Qual Patient Saf. 2022;48(11):612-616. doi:10.1016/j.j… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/74074/psn-pdfNovember 17, 2021 - How safe is prehospital care? A systematic review. November 17, 2021 O’Connor P, O’malley R, Lambe KA, et al. How safe is prehospital care? A systematic review. Int J Qual Health Care. 2021;33(4):mzab138. doi:10.1093/intqhc/mzab138. https://psnet.ahrq.gov/issue/how-safe-prehospital-care-systematic-review Patient s… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46579/psn-pdfApril 11, 2018 - Electronic medicine can send you test results quickly. But what if they're scary? April 11, 2018 Boodman SG. Washington Post. March 26, 2018. https://psnet.ahrq.gov/issue/electronic-medicine-can-send-you-test-results-quickly-what-if-theyre-scary Although providing patients with access to physician notes and test r… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45617/psn-pdfNovember 30, 2016 - Walking a tightrope: balancing the risk of diagnostic error in inpatient pediatrics. November 30, 2016 Berkwitt A, Osborn R, Grossman M. Walking a Tightrope: Balancing the Risk of Diagnostic Error in Inpatient Pediatrics. Hosp Pediatr. 2016;6(9):566-8. doi:10.1542/hpeds.2016-0043. https://psnet.ahrq.gov/issue/walk… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44316/psn-pdfMarch 20, 2017 - Improving Patient Safety: The Intersection of Safety Culture, Clinician and Staff Support, and Patient Safety Organizations. March 20, 2017 Miller RG, Scott SD, Hirschinger LE. Jefferson City, MO: Center for Patient Safety; September 2015. https://psnet.ahrq.gov/issue/improving-patient-safety-intersection-safety-c… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/848089/psn-pdfApril 26, 2023 - Patient Safety Advisory: fentanyl counterfeit prescription medications that contain fentanyl and patient safety. April 26, 2023 Jewell ML, Jewell HL, Singer R, et al. Patient Safety Advisory: fentanyl counterfeit prescription medications that contain fentanyl and patient safety. Aesthetic Plast Surg. 2023;47(3):123… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46132/psn-pdfSeptember 24, 2017 - The "Quality Minute"—a new, brief, and structured technique for quality improvement education during the morbidity and mortality conference. September 24, 2017 Hoffman RL, Morris JB, Kelz RR. The “Quality Minute”—A New, Brief, and Structured Technique for Quality Improvement Education During the Morbidity and Mort… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837059/psn-pdfMay 11, 2022 - Anti-black racism as a chronic condition. May 11, 2022 Sederstrom N, Lasege T. Anti-black racism as a chronic condition. Hastings Cent Rep. 2022;52(S1):s24- s29. doi:10.1002/hast.1364. https://psnet.ahrq.gov/issue/anti-black-racism-chronic-condition Racial bias and systemic racism in healthcare are increasingly se… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50375/psn-pdfSeptember 25, 2019 - Medical error in the care of the unrepresented: disclosure and apology for a vulnerable patient population. September 25, 2019 Byju AS, Mayo K. Medical error in the care of the unrepresented: disclosure and apology for a vulnerable patient population. J Med Ethics. 2019;45(12):821-823. doi:10.1136/medethics-2019-10… -
www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/exh4.htmlAugust 01, 2022 - Designing Consumer Reporting Systems for Patient Safety Events Exhibit 4. Consumer reporting systems-Organizational structure and characteristics Previous Page Next Page Table of Contents Designing Consumer Reporting Systems for Patient Safety Events Executive Summary Chapter 1. Background Cha…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35028/psn-pdfMay 27, 2011 - Medication errors and adverse drug events in pediatric inpatients. May 27, 2011 Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114-20. https://psnet.ahrq.gov/issue/medication-errors-and-adverse-drug-events-pediatric-inpatients This p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73863/psn-pdfSeptember 22, 2021 - Electronic health record interoperability-why electronically discontinued medications are still dispensed. September 22, 2021 Shervani S, Madden W, Gleason LJ. Electronic health record interoperability-why electronically discontinued medications are still dispensed. JAMA Intern Med. 2021;181(10):1383-1384. doi:10… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72650/psn-pdfJanuary 20, 2021 - A roadmap to advance patient safety in ambulatory care. January 20, 2021 Singh H, Carayon P. A roadmap to advance patient safety in ambulatory care. JAMA. 2020;324(24):2481- 2482. doi:10.1001/jama.2020.18551. https://psnet.ahrq.gov/issue/roadmap-advance-patient-safety-ambulatory-care Preventable harm, such as diag… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43966/psn-pdfApril 03, 2017 - TRIAD VII: do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents? April 3, 2017 Mirarchi FL, Cammarata C, Zerkle SW, et al. TRIAD VII: do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents? J Patient Saf. 2015;11(1):9-17. doi:10.1097/PTS… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40028/psn-pdfDecember 01, 2010 - How do black-serving hospitals perform on patient safety indicators?: Implications for national public reporting and pay-for-performance. December 1, 2010 Ly DP, López L, Isaac T, et al. How do black-serving hospitals perform on patient safety indicators? Implications for national public reporting and pay-for-perf… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837675/psn-pdfJuly 13, 2022 - Dashboard design to identify and balance competing risk of multiple hospital-acquired conditions. July 13, 2022 Makic MBF, Stevens KR, Gritz RM, et al. Dashboard design to identify and balance competing risk of multiple hospital-acquired conditions. Appl Clin Inform. 2022;13(3):621-631. doi:10.1055/s-0042-1749598. …
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