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  1. Health Literacy and Patient and Family Engagement: Strategic Tools to Prevent CAUTI | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cauti-tools/archived-webinars/health-literacy-slides.html
    December 01, 2017 - “If you are concerned about falling (or the family is concerned) please let the hospital staff know because … your movement in bed and in your room and may actually make it more difficult to walk and/or lead to falls

  2. Prevehosp-Reports-Ig (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevehosp-reports-ig.pdf
    November 30, 2013 - cellulitis, dehydration, COPD, asthma, circulatory problems, hypertension, gastroenteritis, angina, falls

  3. SOPS Workplace Safety Supplemental Items for Nursing Homes: 2025 Updated Results Part I (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2025_nursing_home_wps_ptI.pdf
    January 01, 2025 - Max Item 1 36% 12.26 8% 10% 25% 35% 49% 62% 96% If your nursing home’s score is 55%, your score falls … here: If your nursing home’s score is 65%, your score falls here: If your nursing home’s score is … 55 percent positive, it falls above the 75th percentile (but below the 90th), meaning that your nursing … If your nursing home’s score is 65 percent positive, it falls above the 90th percentile, meaning your

  4. Final Progress Report: Quality Care and Error Reduction in Rural Hospitals (pdf file)

    www.ahrq.gov/sites/default/files/2024-12/cook-hoas-report.pdf
    January 01, 2024 - of problems most typically recognized and identified as problematic (medication errors and patient falls … encountered only medication-related errors (the wrong time, dose, drug, or mode of delivery), patient falls … hospital detailed organizational efforts to reduce medication errors and, to a lesser degree, patient falls … context, most errors are attributed to the nursing staff, so overall responsibility for patient safety falls

  5. SOPS Workplace Safety Supplemental Items for Nursing Homes: 2025 Updated Results Part I (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2025-nursing-home-workplace-safety-report-pt1.pdf
    January 01, 2025 - Max Item 1 36% 12.26 8% 10% 25% 35% 49% 62% 96% If your nursing home’s score is 55%, your score falls … here: If your nursing home’s score is 65%, your score falls here: If your nursing home’s score is … 55 percent positive, it falls above the 75th percentile (but below the 90th), meaning that your nursing … If your nursing home’s score is 65 percent positive, it falls above the 90th percentile, meaning your

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49748/psn-pdf
    December 01, 2015 - As you drain fluid, the pressure in the abdomen falls exponentially and very rapidly, leading to a rapid

  7. AHRQ Webinar: Optimizing Data Visualization to Improve Care - Q&As (pdf file)

    digital.ahrq.gov/sites/default/files/docs/data-visualization-qas-10192022.pdf
    October 19, 2022 - ANSWER: The flowchart on the FDA webpage may be helpful in determine if an application falls in the FDA

  8. Speaking Up Constructively: Managerial Practices that Elicit Solutions from Front-Line Employees. | PSNet

    psnet.ahrq.gov/issue/speaking-constructively-managerial-practices-elicit-solutions-front-line-employees
    September 05, 2012 - January 30, 2019 WebM&M Cases Falling Between the Cracks

  9. FDA to end program that hid millions of reports on faulty medical devices. | PSNet

    psnet.ahrq.gov/issue/fda-end-program-hid-millions-reports-faulty-medical-devices
    May 17, 2017 - January 15, 2020 ‘Fear of falling’: how hospitals do even more harm by keeping patients

  10. Death by 1,000 clicks: where electronic health records went wrong. | PSNet

    psnet.ahrq.gov/issue/death-1000-clicks-where-electronic-health-records-went-wrong
    September 19, 2018 - January 15, 2020 ‘Fear of falling’: how hospitals do even more harm by keeping patients

  11. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/treat-release.html
    September 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Electronic Reports Table 4. Sample ED Treat and Release Report Facility Name: Month: Average Daily Census 30 Total Transfers (Obs, ED) 11 Resident Days (including bed holds) 300 Tot…

  12. Data Submission Dashboard Data 2025 (xls file)

    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Data_Submission_Dashboard_Data_2025.xlsx
    January 01, 2025 - Introduction Introduction-Data Submission Summary The tables in this workbook present data submitted by AHRQ-listed Patient Safety Organizations (PSOs) to the Network of Patient Safety Databases (NPSD) through December 31, 2024. The tables include distributions of events and unsafe conditions reported by PSOs using …

  13. Clinicians' perspectives on proactive patient safety behaviors in the perioperative environment. | PSNet

    psnet.ahrq.gov/issue/clinicians-perspectives-proactive-patient-safety-behaviors-perioperative-environment
    May 24, 2023 - Study Clinicians' perspectives on proactive patient safety behaviors in the perioperative environment. Citation Text: Duffy C, Menon N, Horak D, et al. Clinicians' perspectives on proactive patient safety behaviors in the perioperative environment. JAMA Netw Open. 2023;6(4):e237621. doi:…

  14. Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services. | PSNet

    psnet.ahrq.gov/issue/patient-safety-factors-and-perceived-consequences-nursing-errors-nursing-staff-home-care
    May 18, 2022 - Study Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services. Citation Text: Jachan DE, Müller‐Werdan U, Lahmann NA. Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services. N…

  15. The relationship between computerized physician order entry and pediatric adverse drug events: a nested matched case-control study. | PSNet

    psnet.ahrq.gov/issue/relationship-between-computerized-physician-order-entry-and-pediatric-adverse-drug-events
    July 13, 2009 - Study The relationship between computerized physician order entry and pediatric adverse drug events: a nested matched case-control study. Citation Text: Yu F, Salas M, Kim Y-I, et al. The relationship between computerized physician order entry and pediatric adverse drug events: a nested…

  16. Department of anesthesiology skilled peer support program outcomes: second victim perceptions. | PSNet

    psnet.ahrq.gov/issue/department-anesthesiology-skilled-peer-support-program-outcomes-second-victim-perceptions
    April 12, 2011 - Study Department of anesthesiology skilled peer support program outcomes: second victim perceptions. Citation Text: Bursch B, Ziv K, Marchese S, et al. Department of anesthesiology skilled peer support program outcomes: second victim perceptions. Jt Comm J Qual Patient Saf. 2024;50(6):44…

  17. The Lawrence D. Dorr Surgical Techniques & Technologies Award: "Running two rooms" does not compromise outcomes or patient safety in joint arthroplasty. | PSNet

    psnet.ahrq.gov/issue/lawrence-d-dorr-surgical-techniques-technologies-award-running-two-rooms-does-not-compromise
    July 29, 2020 - Study The Lawrence D. Dorr Surgical Techniques & Technologies Award: "Running two rooms" does not compromise outcomes or patient safety in joint arthroplasty. Citation Text: Hamilton WG, Ho H, Parks NL, et al. The Lawrence D. Dorr Surgical Techniques & Technologies Award: "Running Two Ro…

  18. Disparities in patient safety voluntary event reporting: a scoping review. | PSNet

    psnet.ahrq.gov/issue/disparities-patient-safety-voluntary-event-reporting-scoping-review
    November 16, 2022 - Review Disparities in patient safety voluntary event reporting: a scoping review. Citation Text: Hoops K, Pittman E, Stockwell DC. Disparities in patient safety voluntary event reporting: a scoping review. Jt Comm J Qual Patient Saf. 2024;50(1):41-48. doi:10.1016/j.jcjq.2023.10.009. Co…

  19. Situation, background, assessment, and recommendation–guided huddles improve communication and teamwork in the emergency department. | PSNet

    psnet.ahrq.gov/issue/situation-background-assessment-and-recommendation-guided-huddles-improve-communication-and
    September 23, 2020 - Study Situation, background, assessment, and recommendation–guided huddles improve communication and teamwork in the emergency department. Citation Text: Martin HA, Ciurzynski SM. Situation, Background, Assessment, and Recommendation-Guided Huddles Improve Communication and Teamwork in t…

  20. Patient safety and image transfer between referring hospitals and neuroscience centres: could we do better? | PSNet

    psnet.ahrq.gov/issue/patient-safety-and-image-transfer-between-referring-hospitals-and-neuroscience-centres-could
    July 19, 2023 - Study Patient safety and image transfer between referring hospitals and neuroscience centres: could we do better? Citation Text: Crocker M, Cato-Addison WB, Pushpananthan S, et al. Patient safety and image transfer between referring hospitals and neuroscience centres: could we do bette…
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