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psnet.ahrq.gov/node/73074/psn-pdf
March 24, 2021 - In U.S. nursing homes, where Covid-19 killed scores, even
reports of maggots and rape don’t dock five-star ratings.
March 24, 2021
Silver-Greenberg J, Gebeloff R. New York Times. March 13, 2021.
https://psnet.ahrq.gov/issue/us-nursing-homes-where-covid-19-killed-scores-even-reports-maggots-and-
rape-dont-dock-five…
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psnet.ahrq.gov/node/74861/psn-pdf
February 23, 2022 - A concept analysis of psychological safety: further
understanding for application to health care.
February 23, 2022
Ito A, Sato K, Yumoto Y, et al. A concept analysis of psychological safety: further understanding for
application to health care. Nurs Open. 2021;9(1):467-489. doi:10.1002/nop2.1086.
https://psnet.ah…
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psnet.ahrq.gov/node/47482/psn-pdf
December 05, 2018 - Examining the effects of an obstetrics interprofessional
programme on reductions to reportable events and their
related costs.
December 5, 2018
Geary M, Ruiter PJA, Yasseen AS. Examining the effects of an obstetrics interprofessional programme on
reductions to reportable events and their related costs. J Interprof…
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psnet.ahrq.gov/node/848813/psn-pdf
May 10, 2023 - Blood and blood products transfusion errors: what can
we do to improve patient safety.
May 10, 2023
Brown C, Brown M. Blood and blood products transfusion errors: what can we do to improve patient
safety? Br J Nurs. 2023;32(7):326-332. doi:10.12968/bjon.2023.32.7.326.
https://psnet.ahrq.gov/issue/blood-and-blood-p…
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psnet.ahrq.gov/node/47957/psn-pdf
April 24, 2019 - A really stupid mistake: it does feel like a cop out to
blame my error on human frailty, but I'm afraid that's
exactly what it was.
April 24, 2019
Maskell G. A really stupid mistake: it does feel like a cop out to blame my error on human frailty, but I'm
afraid that's exactly what it was. BMJ. 2019;365:l1617. doi:…
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digital.ahrq.gov/care-setting/ambulance
January 01, 2023 - Ambulance
Digital EMS Point-of-Care Innovation to Improve Rural STEMI Outcomes
Description
This research will develop, implement, refine, and evaluate an app to support clinical decisions for ST-Elevation Myocardial Infarction care in rural areas by emergency medical services …
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/YhwGborFkVokk_QjRwME9X
Cervical Cancer Screening What You Should Know
Cervical Cancer Screening
What You Should Know
Cervical cancer is one of the most preventable
and treatable types of cancer.
Nearly all cases of cervical cancer
are caused by HPV, and most are in
women who have not been regularly
screened or appropriately treat…
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www.ahrq.gov/cpi/about/nac/snac-shenkman.html
November 01, 2019 - SNAC Member: Elizabeth A. Shenkman, Ph.D.
Professor and Chair
Department of Health Outcomes and Biomedical Informatics
University of Florida College of Medicine
Elizabeth A. Shenkman, Ph.D., is the chair of the Department of Health Outcomes and Biomedical Informatics and the co-director of the University of…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/120-key-strategies-target-mrsa-ssi.pdf
April 01, 2025 - Four Key Strategies To Prevent MRSA & SSI
Four Key Strategies To Prevent MRSA & SSI
AHRQ Safety Program for MRSA Prevention: Targeting SSI | Surgical Services AHRQ Pub. No. 25-0029
April 2025
• Evidence-based infection prevention best
practices should be followed to prevent SSIs.
• Includes best practices …
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psnet.ahrq.gov/node/849134/psn-pdf
May 17, 2023 - Adverse patient safety events during the COVID epidemic.
May 17, 2023
Yackel EE, Knowles RS, Jones CM, et al. Adverse patient safety events during the COVID epidemic. J
Patient Saf. 2023;19(5):340-345. doi:10.1097/pts.0000000000001129.
https://psnet.ahrq.gov/issue/adverse-patient-safety-events-during-covid-epidemic…
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psnet.ahrq.gov/node/867383/psn-pdf
December 18, 2024 - Interactions between the context of a health-care
organisation and failure: the situational impact of failure
on organisational learning.
December 18, 2024
Horck S. Interactions between the context of a health-care organisation and failure: the situational impact of
failure on organisational learning. Leadership H…
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs023805-kutney-lee-final-report-2019.pdf
January 01, 2019 - Approach to Professional Well-Being,” specifically recognized EHR
usability as a contributing work system factor … studies to systematic
reviews, strongly suggests that the work environment is a highly influential factor
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/SaASReVeD_fpHZQbeBZD5s
October 01, 2016 - Dyslipidemia may occur in younger adults (de-
fined as persons aged 21 to 39 years) and is an important risk
factor … individuals with
familial hypercholesterolemia are at increased risk for
early cardiovascular events, a factor
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - administration errors has emphasized the complexity of weight-based dosing as a significant contributing factor … communication—readback and hearback Communication failure is commonly implicated as a key contributing factor
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psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
January 01, 2014 - Advancing and contributing to a research agenda for a topic so fundamentally important is one factor, … Even with documented examples of human factor contributors like interruptions, and other system contributors
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www.ahrq.gov/sites/default/files/2025-02/goldman-report.pdf
January 01, 2025 - Final Progress Report: Evaluating and Improving Present-On-Admission for Performance Reporting
Evaluating and Improving Present-On-Admission for Performance Reporting
L. E lizabeth Goldman, MD, MCR, Principal Investigator
Andrew Bindman, MD, Peter Bacchetti, PhD, Co-Investigators
University of California, San …
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psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx
Spotlight
The Risks of a Malpositioned Gastrostomy Tube and
Poor Communication
Source and Credits
• This presentation is based on the November 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahr…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/fac-notes.html
October 01, 2020 - The Sustainability Scoring Tool
This tool permits the user to rate their facility on key factor areas
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www.ahrq.gov/sites/default/files/2024-10/glance-report.pdf
January 01, 2024 - Final Progress Report: Are Volume Standards Accurate Measures?
FINAL PROGRESS REPORT:
ARE VOLUME STANDARDS ACCURATE MEASURES?
Principal Investigator: Laurent G. Glance, M.D.
Co-Investigators: Andrew W. Dick, Ph.D.
Turner M. Osler, M.D.
Dana B. Mukamel, Ph.D.
Organization: University of Rochester School of Medic…
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www.ahrq.gov/sites/default/files/2024-01/dierks-report.pdf
January 01, 2024 - Final Progress Report: Making Ambulatory Procedural Care Safer: STAMP-Based Risk Assessment and Redesign
1P20HS017118-01 Meghan M. Dierks, MD Beth Israel Deaconess Medical Center
Title of Project:
Making Ambulatory Procedural Care Safer: STAMP-Based Risk Assessment and
Redesign
Principal Investigator and Team …