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psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
January 31, 2020 - February 21, 2020
Perspective
The Role of the FDA in Ensuring
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/VAP-facilitator-guide.pdf
November 01, 2019 - First, ensuring respiratory cultures are sent for all
patients with suspected VAP whenever possible
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psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
October 13, 2018 - provide feedback to institutions and vendors so all can learn how to improve CPOE design and usability; Ensuring
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psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn
February 10, 2010 - Appropriate policies and procedures should assist facilities in ensuring patient safety.
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psnet.ahrq.gov/primer/personal-health-literacy
October 31, 2023 - involve organizational health literacy strategies that will help patients to achieve health literacy: Ensuring
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/social-needs-tool.pdf
May 01, 2021 - For example, ensuring access to healthy foods and providing
supportive housing for people facing homelessness
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - involve organizational health literacy
strategies that will help patients to achieve health literacy:
Ensuring
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psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
February 26, 2025 - Innovation
For the pre-implementation planning phase, according to the innovation team, focus should be on ensuring
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psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
August 05, 2009 - of diverse populations, health care systems and providers should practice "universal precautions" by ensuring
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/daily-care-processes-guide.pdf
January 01, 2017 - Daily Care Processes Guide for Reducing Ventilator-Associated Events in Mechanically Ventilated Patients
AHRQ Safety Program for
Mechanically Ventilated Patients
Daily Care Processes Guide for Reducing
Ventilator-Associated Events in
Mechanically Ventilated Patients
…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/handouts.html
April 01, 2016 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention
Facilitator Training—Handouts: Introduction to Pressure Ulcer Prevention Reports
Contents
Sample Nutrition Report: High Risk
Nutrition Report: Exercise To Spot Potential Inaccuracies
Sample Weight Summary Report
Sample Trigge…
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psnet.ahrq.gov/web-mm/inflicting-confusion
August 04, 2021 - Inflicting Confusion
Citation Text:
Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/web-mm/over-counter-oversight
March 21, 2009 - Over-the-Counter Oversight
Citation Text:
Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML End…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/teambased-1.pdf
May 02, 2016 - Team-Based Primary Care: Convergence of Improving Engagement, Safety, and Enhanced Joy in Practice
Case Study
Problem Addressed
A typical primary care visit is not always a satisfying
encounter for either the provider or the patient. Providers
feel stressed by the need for efficiency and the demands of
electronic…
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psnet.ahrq.gov/node/49869/psn-pdf
July 02, 2019 - Failure to Rescue the Mother
July 2, 2019
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/failure-rescue-mother
The Case
A 27-year-old woman, G5 P2 A2, was first admitted to the hospital at 25 weeks of pregnancy for vaginal
bleeding. An …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Preventing Pressure Injuries in Hospitals
Preventing Pressure Injuries in Hospitals
ADD Name of Hospital Here
Module 1 – Understanding Why Change Is Needed
1
Ice Breaker
Describe an interesting fact about yourself.
2
Compelling Reasons To Implement Program
Pressure injury rates continue to escalate.
The inci…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module2/module2-obtaining-organizational-buy-in-support.pptx
August 14, 2015 - Module 2: Communication and Optimal Resolution (CANDOR) Toolkit Module 2: Obtaining Organizational Buy-in and Support
Communication and Optimal Resolution
(CANDOR)
Toolkit
Module 2: Obtaining Organizational
Buy-in and Support
Module 2 of the CANDOR Toolkit describes the importance of obtaining organizational supp…
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/involving-patients-families-in-safety-slides.pdf
July 25, 2023 - Involving Patients and Families in Safety: Slide Presentation
The National Action Alliance to Advance Patient
Safety Summer Webinar Series
Involving Patients and Families in Safety
July 25, 2023
2:00-3:00 PM ET
Special Guest Speakers
Sue Sheridan,
MIM, MBA, DHL
Founding Member,
Patients For Patient
Safety U…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/tool_safe-e-fetal-monitoring.docx
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Electronic Fetal Monitoring
Purpose of the tool: This tool describes the key perinatal safety elements that support the use of electronic fetal monitoring (EFM). The key safety elements are presented within the framework of the Comprehensive Unit…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
June 01, 2012 - Spotlight Case July 2008
Spotlight Case
Transfer Troubles
1
2
Source and Credits
This presentation is based on the June 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australia…