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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50584/psn-pdf
    October 23, 2019 - Unprotected: broken promises in Georgia’s senior care industry. October 23, 2019 Schrade B, Teegardin C. Atlanta Journal-Constitution. Sept-October 2019. https://psnet.ahrq.gov/issue/unprotected-broken-promises-georgias-senior-care-industry Assisted living facilities have challenges that reduce the quality and saf…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41233/psn-pdf
    March 21, 2012 - ASPEN Parenteral Nutrition Safety Summit. March 21, 2012 Andris DA, Mirtallo JM, Guenter P, eds. JPEN J Parenter Enteral Nutr. 2012;36(2 Suppl):1S-62S.   https://psnet.ahrq.gov/issue/aspen-parenteral-nutrition-safety-summit Articles in this special issue examine parenteral nutrition administration and provide …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42715/psn-pdf
    November 06, 2013 - Identifying Risks and Monitoring Safety: the Role of Patients and Citizens. November 6, 2013 O'Hara J, Isden R. London, UK: Health Foundation; October 2013. https://psnet.ahrq.gov/issue/identifying-risks-and-monitoring-safety-role-patients-and-citizens This report examines how a framework for measuring and monitor…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38974/psn-pdf
    February 18, 2019 - Patient Safety and Adverse Events. February 18, 2019 Adlassnig KP, Blobel B, Mantas J, Masic I, eds. Stud Health Technol Inform. 2009;150:497-566. In: Medical Informatics in a United and Healthy Europe. Washington, DC: IOS Press. ISBN: 9781607500445. https://psnet.ahrq.gov/issue/patient-safety-and-adverse-events P…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38520/psn-pdf
    September 19, 2016 - Inpatient suicide in a general hospital. September 19, 2016 Cheng I-C, Hu F-C, Tseng M-CM. Inpatient suicide in a general hospital. Gen Hosp Psychiatry. 2009;31(2):110-5. doi:10.1016/j.genhosppsych.2008.12.008. https://psnet.ahrq.gov/issue/inpatient-suicide-general-hospital Suicide attempts by hospitalized patient…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42443/psn-pdf
    January 07, 2015 - Medical audible alarms: a review. January 7, 2015 Edworthy J. Medical audible alarms: a review. J Am Med Inform Assoc. 2013;20(3):584-9. doi:10.1136/amiajnl-2012-001061. https://psnet.ahrq.gov/issue/medical-audible-alarms-review This review examines design, implementation, and standardization concerns related to a…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39953/psn-pdf
    October 27, 2010 - Implementing bedside handover: strategies for change management. October 27, 2010 McMurray A, Chaboyer W, Wallis M, et al. Implementing bedside handover: strategies for change management. J Clin Nurs. 2010;19(17-18):2580-9. doi:10.1111/j.1365-2702.2009.03033.x. https://psnet.ahrq.gov/issue/implementing-bedside-han…

  8. CER 45 Self-Measured Blood Pressure Monitoring Comparative Effectiveness Surveillance Final 4.7.16 (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/measuring-blood-pressure-surveillance-160412.pdf
    October 08, 2025 - either$SBP,$DBP,$BP$control,$or$ The$conclusions$are$still$valid.$ One$cluster$RCT$(Margolis$2013)$ examining … Hg,$p<.001),$and$at$18$months$(" 3.0$mm$Hg,$p$=$.07).$ $ One$multi"center$RCT$(McKinstry$ 2013)$examining … $Both$experts$ recommended$ examining$evidence$ from$a$new$IPD$meta" analysis 1 $currently$being … In$ addition,$no$form$of$additional$ support$was$examined$by$ subgroup.$ One$cluster$RCT 6 $ examining … months$(" 5.1$mm$Hg,$p<.001),$and$ at$18$months$("3.0$mm$ Hg,$p$=$.07).$ One$multi"center$RCT 7 $ examining

  9. Access to Outpatient Child and Adolescent Psychiatrists, Neurodevelopmental Pediatricians, and Developmental-Behavioral Pediatricians (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-236-fullreport.pdf
    October 01, 2018 - Examining credentials for developmental-behavioral and neurodevelopmental pediatricians with <90 percent

  10. CHIPRA 241: Section 1, Table 1 (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-241-bmi-communication-section-1-table-1.pdf
    June 02, 2025 - CHIPRA 241: Section 1, Table 1 Table 1: Codes to Identify Outpatient Care Visits Description CPT HCPCS ICD-9-CM Diagnosis Office or other outpatient services 99201-99205, 99211-99215, 99241-99245 Preventive medicine 99381-99385, 99391-99395, 99401-99404, 99411-99412, 99420, 99429 G0438, G0439 Ge…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34975/psn-pdf
    June 14, 2011 - Don't be fooled by the illusion of patient safety. June 14, 2011 Spath P. Don't be fooled by the illusion of patient safety. Hosp Peer Rev. 2005;30(5):69-71. https://psnet.ahrq.gov/issue/quality-cot-connection-dont-be-fooled-illusion-patient-safety The author examines the pros and cons of using root cause analysis …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857580/psn-pdf
    August 09, 2024 - Patient Safety Research Summaries. August 9, 2024 Rockville, MD: Agency for Healthcare Research and Quality; 2023-2024.  https://psnet.ahrq.gov/issue/patient-safety-research-summaries The application of evidence in real situations helps to embed innovation across systems and sustain care improvement. This col…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37380/psn-pdf
    June 16, 2019 - ISMP medication error report analysis. June 16, 2019 Cohen MR. Hosp Pharm. 2007;42(11):982-985. https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-19 This monthly commentary examines risks associated with mismanagement of IV tubing and ports, discusses a recent article regarding unintended conseque…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39492/psn-pdf
    May 05, 2010 - Use of information technology in medication reconciliation: a scoping review. May 5, 2010 Bassi J, Lau F, Bardal S. Use of information technology in medication reconciliation: a scoping review. Ann Pharmacother. 2010;44(5):885-97. doi:10.1345/aph.1M699. https://psnet.ahrq.gov/issue/use-information-technology-medic…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40087/psn-pdf
    December 15, 2010 - Managing patient access and flow in the emergency department to improve patient safety. December 15, 2010 PA-PSRS Patient Saf Advis. 2010;7:123-134.  https://psnet.ahrq.gov/issue/managing-patient-access-and-flow-emergency-department-improve-patient- safety This report examines how optimizing patient flow fro…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73548/psn-pdf
    July 27, 2021 - Diagnostic Errors in Primary Care. July 27, 2021 Betsy Lehman Center for Patient Safety. https://psnet.ahrq.gov/issue/diagnostic-errors-primary-care Case analysis provides important opportunities to highlight factors that culminate in diagnostic error. This website supports learning generated from the Primary-Care…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42427/psn-pdf
    July 17, 2013 - Residual anaesthesia drugs in intravenous lines—a silent threat? July 17, 2013 Bowman S, Raghavan K, Walker IA. Residual anaesthesia drugs in intravenous lines--a silent threat? Anaesthesia. 2013;68(6):557-61. doi:10.1111/anae.12287. https://psnet.ahrq.gov/issue/residual-anaesthesia-drugs-intravenous-lines-silent-…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42331/psn-pdf
    June 05, 2013 - Using the ABCs of situational awareness for patient safety. June 5, 2013 Cohen NL. Using the ABCs of situational awareness for patient safety. Nursing (Brux). 2013;43(4):64-5. doi:10.1097/01.NURSE.0000428332.23978.82. https://psnet.ahrq.gov/issue/using-abcs-situational-awareness-patient-safety This commentary exa…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33957/psn-pdf
    February 05, 2018 - State Patient Safety Centers: A New Approach to Promote Patient Safety. February 5, 2018 Rosenthal J, Booth M. Portland, ME National Academy for State Health Policy; October 2004. https://psnet.ahrq.gov/issue/state-patient-safety-centers-new-approach-promote-patient-safety Six states have enacted legislation to su…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38382/psn-pdf
    September 26, 2016 - Interruptions and blood transfusion checks: lessons from the simulated operating room. September 26, 2016 Liu D, Grundgeiger T, Sanderson P, et al. Interruptions and blood transfusion checks: lessons from the simulated operating room. Anesth Analg. 2009;108(1):219-22. doi:10.1213/ane.0b013e31818e841a. https://psne…
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