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psnet.ahrq.gov/issue/designing-and-delivering-whole-person-transitional-care-hospital-guide-reducing-medicaid
March 27, 2019 - Toolkit
Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions.
Citation Text:
Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions. Boutwell A, Bourgoin A , Maxwell J, et al. Rockvill…
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psnet.ahrq.gov/issue/medication-bar-coding-scan-or-not-scan
October 19, 2022 - September 24, 2016
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/issue/patient-safety-and-acute-care-medicine-lessons-future-insights-past
April 27, 2022 - September 23, 2020
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/issue/government-and-industry-fail-protect-public-when-they-suggest-carefully-following
February 24, 2016 - Same Author(s)
Selected medication safety risks to manage in 2016 that might otherwise fall
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults2.html
September 01, 2024 - Recent research from the Centers for Disease Control and Prevention suggests that about 10 percent of
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psnet.ahrq.gov/node/34766/psn-pdf
March 05, 2013 - Making Health Care Safer: A Critical Analysis of Patient
Safety Practices.
March 5, 2013
Shojania KG, Duncan BW, McDonald KM, et al, eds. Rockville, MD: Agency for Healthcare Research and
Quality; July 2001. AHRQ Publication No. 01-E058.
https://psnet.ahrq.gov/issue/making-health-care-safer-critical-analysis-patie…
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psnet.ahrq.gov/node/43207/psn-pdf
April 25, 2016 - Root cause analysis of serious adverse events among
older patients in the Veterans Health Administration.
April 25, 2016
Lee A, Mills PD, Neily J, et al. Root cause analysis of serious adverse events among older patients in the
Veterans Health Administration. Jt Comm J Qual Patient Saf. 2014;40(6):253-62.
https://…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
November 01, 2006 - Surgical Infection Prevention
• Prophylactic antibiotic received within 1 hour prior to surgical incision … publicly reporting hospital specific mortality following coronary bypass surgery, rates were observed to fall … with reported measures may entail unintended consequences
Systems should be in place for monitoring, prevention
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www.ahrq.gov/faqs/index.html
July 10, 2025 - All four modules rely solely on hospital inpatient administrative data:
Prevention Quality Indictors … The Technical Specifications for each QI module—Prevention Quality Indicators (PQI), Inpatient Quality … ICD-9-CM v6.0 software, when available in the fall of 2016, or prior software can be used with the ICD
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www.ahrq.gov/faqs/index.html?page=0
All four modules rely solely on hospital inpatient administrative data:
Prevention Quality Indictors … The Technical Specifications for each QI module—Prevention Quality Indicators (PQI), Inpatient Quality … ICD-9-CM v6.0 software, when available in the fall of 2016, or prior software can be used with the ICD
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psnet.ahrq.gov/node/61082/psn-pdf
July 23, 2020 - or Medicaid have in place an Infection
Prevention and Control Program and an Infection Preventionist … Rural LTC facilities in
particular may suffer from a dearth of infection prevention expertise. … Weaknesses in infection prevention
and control expertise, coupled with the unprecedented nature of a … Centers for Disease
Control and Prevention. https://www.cdc.gov/covid/risk-
factors/? … Changes in US nursing home infection prevention and
control programs from 2014 to 2018.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
January 01, 2019 - Comparing these data with other sources of information, such as the Centers
for Disease Control and Prevention … measured with MPSMS, the AHRQ Patient Safety Indicators
(PSIs), the Centers for Disease Control and Prevention
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psnet.ahrq.gov/issue/patient-safety-ed
August 11, 2010 - Newspaper/Magazine Article
Patient safety in the ED.
Citation Text:
Patient safety in the ED. Hospitals & health networks. 2006;80(5):6 p. following 48, 2.
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Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/issue/root-cause-analysis-playbook
July 05, 2017 - Book/Report
Root Cause Analysis Playbook.
Citation Text:
Root Cause Analysis Playbook. Chicago, IL: American Society for Healthcare Risk Management; 2015.
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psnet.ahrq.gov/issue/alarm-fatigue-hazards-sirens-are-calling
November 16, 2022 - Newspaper/Magazine Article
Alarm fatigue hazards: the sirens are calling.
Citation Text:
Alarm fatigue hazards: the sirens are calling. Welch J.
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www.ahrq.gov/talkingquality/measures/setting/physician/examples.html
September 01, 2019 - Examples of Physician Quality Measures for Consumers
Following are a few examples of physician quality measures that research evidence and practical experience suggest are appropriate for reporting to consumers. The list is categorized by the Institute of Medicine’s domains for a quality health care system; for…
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psnet.ahrq.gov/issue/using-workforce-practices-drive-quality-improvement-guide-hospitals
March 22, 2017 - Book/Report
Using Workforce Practices to Drive Quality Improvement: A Guide for Hospitals.
Citation Text:
Using Workforce Practices to Drive Quality Improvement: A Guide for Hospitals. McHugh M, Garman A, McAlearney A, Song P, Harrison M. Chicago, IL: Health Research & Educational Tr…
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psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
August 21, 2016 - s Bureau Learning and Coordination Center (CBLCC) , Prevent Child Abuse America , The Child Abuse Prevention … Lesson from the VA's Team Training Program
November 1, 2011
Detection and prevention
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psnet.ahrq.gov/issue/strategic-solution-preventing-harm-associated-ambulance-handover-delays
July 22, 2020 - Journal Article
Study
Catching those who fall
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qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ.pdf
August 31, 2016 - following:
PSI 03 Pressure Ulcer Rate
PSI 06 Iatrogenic Pneumothorax Rate
PSI 08 In-Hospital Fall … PSI 08 (In-Hospital Fall with Hip Fracture Rate) now targets all hip fractures
from inpatient … specification, the name of the indicator was changed from
“Postoperative Hip Fracture Rate” to “In-Hospital Fall … Central Venous Catheter-Related
Blood Stream Infection Rate
0.037684 -- N/A
PSI 08 In-Hospital Fall