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  1. 105-What-Are-The-4-Es-Notes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/105-what-are-the-4-es-notes.docx
    April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI What Are the 4 Es? Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries Slide Title and Commentary Slide Number and Slide What Are the 4 Es? SAY: This presentation reviews the 4 Es, a framework to guide the implementation…

  2. Safe Practices for Better Health Care (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer1.pdf
    April 01, 2004 - Safe Practices for Better Health Care 23 Safe Practices for Better Health Care Kenneth W. Kizer, Laura N. Blum Abstract Modern health care is highly complex, high risk, and error prone. Not surprisingly, health care errors and consequent adverse events are a leading cause of death and injury, even though wel…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47524/psn-pdf
    June 19, 2019 - Learning from patients' experiences related to diagnostic errors is essential for progress in patient safety. June 19, 2019 Giardina TD, Haskell H, Menon S, et al. Learning From Patients' Experiences Related To Diagnostic Errors Is Essential For Progress In Patient Safety. Health Aff (Millwood). 2018;37(11):1821-18…

  4. P A W S, Prescription for Antibiotics or Wait and See: Ear Infections: Are Antibiotics the Right Choice for You? (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/ebc-challenge-2ndplace-paws.pdf
    May 29, 2025 - P A W S, Prescription for Antibiotics or Wait and See: Ear Infections: Are Antibiotics the Right Choice for You? P A W S Prescription for Antibiotics or Wait and See Ear Infections Are Antibiotics the Right Choice for You? Your path to good health begins with visiting your retail health pro…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39797/psn-pdf
    September 20, 2011 - Liability claims and costs before and after implementation of a medical error disclosure program. September 20, 2011 Kachalia A, Kaufman SR, Boothman RC, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010;153(4):213-21. doi:10.7326/0003-4819…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44831/psn-pdf
    January 27, 2016 - IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events. January 27, 2016 Adler L, Moore J, Federico F. Cambridge, MA: Institute for Healthcare Improvement; November 2015. https://psnet.ahrq.gov/issue/ihi-skilled-nursing-facility-trigger-tool-measuring-adverse-events Prior research has shown that sa…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47921/psn-pdf
    June 18, 2019 - Using incident reports to assess communication failures and patient outcomes. June 18, 2019 Umberfield E, Ghaferi AA, Krein SL, et al. Using Incident Reports to Assess Communication Failures and Patient Outcomes. Jt Comm J Qual Patient Saf. 2019;45(6):406-413. doi:10.1016/j.jcjq.2019.02.006. https://psnet.ahrq.gov…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45652/psn-pdf
    June 29, 2017 - Increases in drug and opioid overdose deaths—United States, 2000–2015. June 29, 2017 Rudd RA, Seth P, David F, et al. Increases in Drug and Opioid-Involved Overdose Deaths - United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(50-51):1445-1452. doi:10.15585/mmwr.mm655051e1. https://psnet.ahrq.gov/issue/inc…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46098/psn-pdf
    July 24, 2017 - Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: the Promoting Respect and Ongoing Safety through Patient Engagement Communication and Technology study. July 24, 2017 Dykes PC, Rozenblum R, Dalal A, et al. Prospective Evaluation of a Multifaceted Intervention to Improve …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46542/psn-pdf
    June 19, 2018 - Improving admission medication reconciliation with pharmacists or pharmacy technicians in the emergency department: a randomised controlled trial. June 19, 2018 Pevnick JM, Nguyen C, Jackevicius CA, et al. Improving admission medication reconciliation with pharmacists or pharmacy technicians in the emergency depar…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45231/psn-pdf
    February 14, 2017 - 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. February 14, 2017 Barker AL, Morello RT, Wolfe R, et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. BMJ. 2016;352:h6781. doi:10.1136/bmj.h6781. https://psnet.…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39457/psn-pdf
    April 12, 2011 - Disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and influencing factors. April 12, 2011 Matlow AG, Moody L, Laxer R, et al. Disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and influencing factors. Arch Dis Child. 2009…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39404/psn-pdf
    March 31, 2010 - Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study. March 31, 2010 Cohen SP, Hayek SM, Datta S, et al. Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study. Anesthesiology. 2010;112(3):711-8. doi:10.1097/ALN.0b013e3181cf892d. h…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37462/psn-pdf
    January 06, 2017 - Medication errors associated with code situations in U.S. hospitals: direct and collateral damage. January 6, 2017 Lipshutz AKM, Morlock LL, Shore AD, et al. Medication Errors Associated with Code Situations in U.S. Hospitals: Direct and Collateral Damage. Jt Comm J Qual Patient Saf. 2016;34(1):46-56. doi:10.1016/…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44266/psn-pdf
    May 19, 2019 - Exploring health care professionals' perceptions of incidents and incident reporting in rehabilitation settings. May 19, 2019 Espin S, Carter C, Janes N, et al. Exploring Health Care Professionals' Perceptions of Incidents and Incident Reporting in Rehabilitation Settings. J Patient Saf. 2019;15(2):154-160. doi:10…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47226/psn-pdf
    August 01, 2018 - Development of a standardized, citywide process for managing smart-pump drug libraries. August 1, 2018 Walroth TA, Smallwood S, Arthur KJ, et al. Development of a standardized, citywide process for managing smart-pump drug libraries. Am J Health Syst Pharm. 2018;75(12):893-900. doi:10.2146/ajhp170262. https://psne…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47088/psn-pdf
    May 02, 2018 - Medical Office Survey on Patient Safety Culture: 2018 User Database Report. May 2, 2018 Famolaro T, Yount N, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0030-EF. https://psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture-2018-user-dat…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42693/psn-pdf
    December 23, 2016 - Preventing unintended retained foreign objects. December 23, 2016 Preventing unintended retained foreign objects. Sentinel event alert. 2013;(51):1-5. https://psnet.ahrq.gov/issue/preventing-unintended-retained-foreign-objects Sentinel event alerts are issued periodically by The Joint Commission to identify common …

  19. Introduction | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/probabilistic-thinking1.html
    September 01, 2022 - Improved Diagnostic Accuracy Through Probability-Based Diagnosis Introduction Previous Page Next Page Table of Contents Improved Diagnostic Accuracy Through Probability-Based Diagnosis Introduction Fundamental Concepts for Understanding Probability Probability and the Diagnostic Pathway Futu…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44823/psn-pdf
    February 15, 2017 - US poison control center calls for infants 6 months of age and younger. February 15, 2017 Kang M, Brooks DE. US Poison Control Center Calls for Infants 6 Months of Age and Younger. Pediatrics. 2016;137(2):e20151865. doi:10.1542/peds.2015-1865. https://psnet.ahrq.gov/issue/us-poison-control-center-calls-infants-6-m…
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