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psnet.ahrq.gov/node/60044/psn-pdf
March 16, 2020 - Despite improvements over the past two
decades, patient safety and quality of care
still need to be enhanced
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/cre.pdf
September 26, 2019 - hospital’s multi-faceted intervention included antibiotic
stewardship measures, contact isolation, and enhanced … Toth et al.,
201719
• Enhanced contact isolation
• Active surveillance
The model’s intervention … Active
surveillance and enhanced contact isolation were found to be successful in one model of LTACHs … high
Organism: CP-KP
Toth et al.,
201719
Mathematical
model that
measured the
effects of
enhanced … The enhanced isolation
model accounted for patients
contributing 75% less to
transmission rate compared
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallspximpl-ig.pdf
June 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training
AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention 1
On-Time Falls
Prevention:
Implementation
AHRQ’s Safety Program for Nursing
Homes: On-Time Falls Prevention
Facilitator Training
Implementatio…
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www.ahrq.gov/hai/tools/mvp/modules/cusp/build-business-case-fac-guide.html
February 01, 2017 - Build a Business Case for Quality Improvement: Facilitator Guide
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: Build a Business Case for Quality Improvement
Say:
This slide set introduces building a business case for quality improvement.
Slide 2: Learning Objectives
Say:
Afte…
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psnet.ahrq.gov/node/49863/psn-pdf
May 01, 2019 - Good Catch in the Operating Room
May 1, 2019
Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/good-catch-operating-room
The Case
A 46-year-old woman with extensive history of back pain from lumbar stenosis was scheduled for an
elective laminectomy and spinal…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/facguide.html
December 01, 2017 - Process efficiencies and enhanced team communication save the staff time.
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu4a.html
October 01, 2014 - For example, you might have information sheets for the staff outlining changes to proactive, enhanced
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www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu4a.html
October 01, 2014 - For example, you might have information sheets for the staff outlining changes to proactive, enhanced
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digital.ahrq.gov/ahrq-funded-projects/success-stories/text-messaging-managing-chronic-disease
January 01, 2023 - Text Messaging for Managing Chronic Disease
Your browser does not support inline frames. Please go to http://youtu.be/bpP8xawfoi4 to view the video. Principal Investigator: Jennifer Uhrig (Contract No. HHSA290200600001I #7) [5 min., 10 sec.] This project showed that text messaging can effec…
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psnet.ahrq.gov/node/46039/psn-pdf
April 05, 2017 - Retained lumbar catheter tip.
April 5, 2017
DeLancey JO, Barnard C, Bilimoria KY. Retained Lumbar Catheter Tip. JAMA. 2017;317(12):1269-1270.
doi:10.1001/jama.2017.1713.
https://psnet.ahrq.gov/issue/retained-lumbar-catheter-tip
Retained surgical items are considered a sentinel event. Discussing an incident involvi…
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psnet.ahrq.gov/node/42521/psn-pdf
August 21, 2013 - Why your TeamSTEPPS program may not be working.
August 21, 2013
Clapper TC, Ng GM. Why Your TeamSTEPPS™ Program May Not Be Working. Clin Simul Nurs.
2012;9(8). doi:10.1016/j.ecns.2012.03.007.
https://psnet.ahrq.gov/issue/why-your-teamstepps-program-may-not-be-working
This commentary explores barriers to implementi…
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psnet.ahrq.gov/node/39384/psn-pdf
March 24, 2010 - Keeping safety a priority in home care and hospice: one
agency's journey.
March 24, 2010
Mullin LV. Keeping safety a priority in home care and hospice: one agency's journey. Home Healthc Nurse.
2010;28(2):63-70. doi:10.1097/NHH.0b013e3181cb5939.
https://psnet.ahrq.gov/issue/keeping-safety-priority-home-care-and-ho…
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psnet.ahrq.gov/node/865819/psn-pdf
May 08, 2024 - Focus on HARM (Harmonizing Accountability in
Reporting and Monitoring).
May 8, 2024
National Quality Forum.
https://psnet.ahrq.gov/issue/focus-harm-harmonizing-accountability-reporting-and-monitoring
Strong incident reporting systems are a foundational component for understanding preventable health care
error. Th…
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psnet.ahrq.gov/node/42765/psn-pdf
November 30, 2016 - Advancing Patient Safety Implementation Through Safe
Medication Use Research (R18).
November 30, 2016
Rockville, MD: Agency for Healthcare Research and Quality. PA-14-002.
https://psnet.ahrq.gov/issue/advancing-patient-safety-implementation-through-safe-medication-use-
research-r18
This funding program will suppo…
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psnet.ahrq.gov/node/42256/psn-pdf
May 10, 2013 - Rapid response systems: should we still question their
implementation?
May 10, 2013
Winters BD, Pronovost P. Rapid response systems: should we still question their implementation? J Hosp
Med. 2013;8(5):278-81. doi:10.1002/jhm.2050.
https://psnet.ahrq.gov/issue/rapid-response-systems-should-we-still-question-their-…
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psnet.ahrq.gov/node/45414/psn-pdf
August 17, 2016 - The next wave of hospital innovation to make patients
safer.
August 17, 2016
Ghaferi AA; Myers C; Sutcliffe KM; Pronovost PJ.
https://psnet.ahrq.gov/issue/next-wave-hospital-innovation-make-patients-safer
Achieving high reliability is a recognized goal for health care organizations. Reviewing current technical and…
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psnet.ahrq.gov/node/46708/psn-pdf
February 08, 2023 - FDA/ISMP Safe Medication Management Fellowship
Program.
February 8, 2023
Food and Drug Administration, Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/fdaismp-safe-medication-management-fellowship-program
This fellowship program provides clinicians with learning opportunities at the Institute…
-
psnet.ahrq.gov/node/72863/psn-pdf
March 17, 2021 - 7 ways to prevent medical errors.
March 17, 2021
Caceres V. US News World Report. March 1, 2021.
https://psnet.ahrq.gov/issue/7-ways-prevent-medical-errors
Patients and families have an important role in reducing potential for error and harm. This article highlights
a set of tactics for patients to enhan…
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psnet.ahrq.gov/node/41009/psn-pdf
December 21, 2011 - Improving ambulatory patient safety: learning from the
last decade, moving ahead in the next.
December 21, 2011
Wynia MK, Classen DC. Improving Ambulatory Patient Safety. JAMA. 2011;306(22):2504-2505.
doi:10.1001/jama.2011.1820.
https://psnet.ahrq.gov/issue/improving-ambulatory-patient-safety-learning-last-decade-…
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psnet.ahrq.gov/node/44720/psn-pdf
December 16, 2015 - The persistent problem of diagnostic error.
December 16, 2015
Lundberg GD. Medscape. December 1, 2015.
https://psnet.ahrq.gov/issue/persistent-problem-diagnostic-error
Spotlighting the author's experience with autopsies to provide context regarding diagnostic errors as a
patient safety problem, this commentary out…