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psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
February 26, 2025 - reconciliation : For sites seeking to improve the medication reconciliation as part of readmission prevention … Innovations
Preventing Falls Through Patient and Family Engagement to Create Customized Prevention
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psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-mitigation-storm-shows
October 30, 2024 - Health Administration Stratification Tool for Opioid Risk Mitigation (STORM) Shows Promise for Targeting Prevention … STORM is one of several VHA overdose prevention initiatives that include the distribution of naloxone … Targeted Prevention Program Implementation: The implementation of the STORM targeted prevention program … Office of Mental Health and Suicide Prevention, US Dept of Veterans Affairs; 2021. … Office of Mental Health and Suicide Prevention, US Dept of Veterans Affairs; 2021.
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psnet.ahrq.gov/node/867359/psn-pdf
December 18, 2024 - Centers for Disease Control and Prevention. July 31,
2024. [Free full text]
3. … Centers for Disease Control and Prevention. June 11, 2024.
Accessed December 6, 2024. … Centers for Disease Control and Prevention. June 28, 2024.
Accessed December 6, 2024. … Centers for Disease Control and Prevention. December 13, 2023.
Accessed December 6, 2024. … Medical Error Reduction and Prevention. [Updated
2024 Feb 12]. In: StatPearls [Internet].
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psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - Combine this prevention strategy with a spirit of continuous learning from successes and failures, and … Ideally, an industry would mobilize itself to take a stand on safety and harm prevention issues.
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psnet.ahrq.gov/node/50615/psn-pdf
October 30, 2019 - Misidentifying the Unidentified – John Doe and the EHR
October 30, 2019
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
The Case
Two male patients of similar age arrived at the same …
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psnet.ahrq.gov/node/49667/psn-pdf
October 01, 2012 - Many of the steps and techniques described above fall under the field of medication safety engineering
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
February 01, 2017 - PowerPoint Presentation
Spotlight
The Hazards of Distraction: Ticking All the EHR Boxes
*
Source and Credits
This presentation is based on the February 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Anthony C. Easty, PhD, Adjunct Pr…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.326_slideshow.ppt
June 01, 2014 - PowerPoint Presentation
Spotlight
Wandering Off the Floors: Safety and Security Risks of Patient Wandering
1
This presentation is based on the June 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Thomas A. Smith, CHPA, CPP, President, Healthc…
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psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
July 19, 2023 - Liem et al. determined to be about 37%. 12 Risk of Infection The Centers for Disease Control and Prevention … need for vigilance by hospital staff in appropriate line selection and adherence to sound infection prevention … , CNL, NEA-BC, FACHE Executive Director Patient Care Services, Quality & Safety, Hospital Infection Prevention … Guidelines for the prevention of intravascular catheter-related infections. … Consensus conference on prevention of central line-associated bloodstream infections: 2009.
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psnet.ahrq.gov/web-mm/code-status-vs-care-status
September 30, 2020 - With the development of EHR, more clerical and administrative tasks fall on all healthcare providers,
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psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
December 23, 2020 - Take-Home Points An EHR facilitates error prevention at the point of care, as a first layer of protection … Innovations
Preventing Falls Through Patient and Family Engagement to Create Customized Prevention
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psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
May 01, 2014 - setting, hospitals continue to struggle with suboptimal rates of compliance with this basic infection prevention … remarkable given widespread agreement that hand hygiene is the most important intervention for infection prevention … include insufficient time, work overload, inadequate knowledge, skepticism about hand hygiene as a prevention … Infection prevention promotion program based on the PRECEDE model: improving hand hygiene behaviors among … Related Resources From the Same Author(s)
Positive deviance: a new tool for infection prevention
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psnet.ahrq.gov/web-mm/elopement
July 14, 2010 - These protocols should include assessment and prevention procedures to reduce the risk of harm for patients … Miscarriage
June 1, 2003
WebM&M Cases
Another Fall
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.161_slideshow.ppt
October 01, 2007 - Professional Health
Take-Home Points
Professionalism is a core competency for all physicians
Prevention
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psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn
February 10, 2010 - Ambulatory Surgery Anesthesia for ambulatory surgery focuses on (i) rapid emergence and awakening, (ii) prevention
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psnet.ahrq.gov/web-mm/pill-organizing-plight
June 19, 2018 - SPOTLIGHT CASE
A Pill Organizing Plight
Citation Text:
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTe…
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psnet.ahrq.gov/node/49704/psn-pdf
March 01, 2014 - providers who all noted that the
hemoglobin remained stable at 12 g/dL, and the bilirubin continued to fall
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psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - Lane-Fall MB, Beidas RS, Pascual JL, et al.
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psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
December 15, 2024 - Improving Patient Safety and Team Communication through Daily Huddles
Citation Text:
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
Copy Citatio…
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psnet.ahrq.gov/web-mm/nstemi-curbside-consultation
August 04, 2021 - patients with MI, 21 and additional monitoring of cTn might have led to the recognition of a “rise and fall … case exemplifies many of the following known major disparities in CVD between men and women:
Under-prevention … Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, et al. 2019 ACC/AHA Guideline on the Primary Prevention … Summary of Updated Recommendations for Primary Prevention of Cardiovascular Disease in Women. … Effectiveness-based guidelines for the prevention of cardiovascular disease in women--2011 update: a