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psnet.ahrq.gov/node/45681/psn-pdf
January 25, 2017 - Economic evaluation of quality improvement
interventions for bloodstream infections related to central
catheters: a systematic review.
January 25, 2017
Nuckols TK, Keeler E, Morton SC, et al. Economic Evaluation of Quality Improvement Interventions for
Bloodstream Infections Related to Central Catheters: A Systema…
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psnet.ahrq.gov/node/46112/psn-pdf
December 21, 2017 - Analysis of variations in the display of drug names in
computerized prescriber-order-entry systems.
December 21, 2017
Quist AJL, Hickman T-TT, Amato MG, et al. Analysis of variations in the display of drug names in
computerized prescriber-order-entry systems. American Journal of Health-System Pharmacy. 2017;74(7).
…
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psnet.ahrq.gov/node/46203/psn-pdf
June 14, 2017 - Prescription errors related to the use of computerized
provider order-entry system for pediatric patients.
June 14, 2017
Alhanout K, Bun S-S, Retornaz K, et al. Prescription errors related to the use of computerized provider
order-entry system for pediatric patients. Int J Med Inform. 2017;103:15-19.
doi:10.1016/j…
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psnet.ahrq.gov/node/46599/psn-pdf
August 20, 2018 - Effect of standardized handoff curriculum on improved
clinician preparedness in the intensive care unit: a
stepped-wedge cluster randomized clinical trial.
August 20, 2018
Parent B, LaGrone LN, Albirair MT, et al. Effect of Standardized Handoff Curriculum on Improved Clinician
Preparedness in the Intensive Care Un…
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psnet.ahrq.gov/node/35979/psn-pdf
September 17, 2010 - How will we know patients are safer? An organization-
wide approach to measuring and improving safety.
September 17, 2010
Pronovost P, Holzmueller CG, Needham DM, et al. How will we know patients are safer? An organization-
wide approach to measuring and improving safety. Crit Care Med. 2006;34(7):1988-95.
https:/…
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psnet.ahrq.gov/node/44102/psn-pdf
May 06, 2015 - Factors that influence the recognition, reporting and
resolution of incidents related to medical devices and
other healthcare technologies: a systematic review.
May 6, 2015
Polisena J, Gagliardi AR, Urbach DR, et al. Factors that influence the recognition, reporting and resolution
of incidents related to medical d…
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psnet.ahrq.gov/node/46724/psn-pdf
April 12, 2019 - Association of household opioid availability and
prescription opioid initiation among household members.
April 12, 2019
Seamans MJ, Carey TS, Westreich DJ, et al. Association of Household Opioid Availability and Prescription
Opioid Initiation Among Household Members. JAMA Intern Med. 2018;178(1):102-109.
doi:10.10…
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psnet.ahrq.gov/node/42530/psn-pdf
December 30, 2014 - What attributes of patients affect their involvement in
safety? A key opinion leaders' perspective.
December 30, 2014
Buetow S, Davis R, Callaghan K, et al. What attributes of patients affect their involvement in safety? A key
opinion leaders' perspective. BMJ Open. 2013;3(8):e003104. doi:10.1136/bmjopen-2013-00310…
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psnet.ahrq.gov/node/41031/psn-pdf
February 10, 2012 - Is patient safety improving? National trends in patient
safety indicators: 1998–2007.
February 10, 2012
Downey JR, Hernandez-Boussard T, Banka G, et al. Is patient safety improving? National trends in patient
safety indicators: 1998-2007. Health Serv Res. 2012;47(1 Pt 2):414-30. doi:10.1111/j.1475-
6773.2011.01361…
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psnet.ahrq.gov/node/42548/psn-pdf
December 29, 2014 - What is known about adverse events in older medical
hospital inpatients? A systematic review of the literature.
December 29, 2014
Long SJ, Brown KF, Ames D, et al. What is known about adverse events in older medical hospital
inpatients? A systematic review of the literature. Int J Health Care Qual. 2013;25(5):542-5…
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psnet.ahrq.gov/node/43037/psn-pdf
October 31, 2014 - Adverse Events in Skilled Nursing Facilities: National
Incidence Among Medicare Beneficiaries.
October 31, 2014
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector
General; February 2014. Report No. OEI-06-11-00370.
https://psnet.ahrq.gov/issue/adverse-events-skilled-nu…
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psnet.ahrq.gov/node/45483/psn-pdf
March 20, 2018 - Impact of initial hospital diagnosis on mortality for acute
myocardial infarction: a national cohort study.
March 20, 2018
Wu J, Gale CP, Hall M, et al. Editor's Choice - Impact of initial hospital diagnosis on mortality for acute
myocardial infarction: A national cohort study. Eur Heart J Acute Cardiovasc Care. 20…
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psnet.ahrq.gov/glossary/failure-mode-and-effect-analysis-fmea
September 13, 2021 - Failure Mode and Effect Analysis (FMEA)
September 13, 2021
Anonymous (not verified)
A common process used to prospectively identify error risk within a particular process. FMEA begins with a complete process mapping that identifies all the steps that must occur for a given process to occur (e.g., programming an…
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www.ahrq.gov/data/hcup/mental-disorders.html
May 01, 2023 - Geographic Variation in Inpatient Stays for Five Leading Mental Disorders, 2016-2018
This visualization presents rates of hospitalization per 100,000 population for mental disorders during the 3-year period 2016-2018, comparing national, State, and substate areas. Based on an analysis of data from AHRQ's Health…
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www.ahrq.gov/action-alliance/index.html
National Action Alliance for Patient and Workforce Safety
Overview of the National Action Alliance for Patient and Workforce Safety
Vision, Mission, and Aims.
National Ac…
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www.ahrq.gov/sites/default/files/publications/files/hacrate2013_0.pdf
October 01, 2015 - An estimated 1.3 million fewer harms were
experienced by patients from 2010 to 2013 than would have
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psnet.ahrq.gov/perspective/safety-culture-ems
May 26, 2021 - How do we shift the thinking to the idea that these are harms that may happen to the patient, be it a
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psnet.ahrq.gov/node/73334/psn-pdf
August 01, 2024 - An Inadvertent Bolus of Norepinephrine.
May 26, 2021
Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counc…
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psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
December 04, 2016 - SPOTLIGHT CASE
An Inadvertent Bolus of Norepinephrine.
Citation Text:
Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/asd-interventions-disposition.pdf
May 26, 2017 - Interventions Targeting Sensory Challenges in Children With Autism Spectrum Disorders - An Update
Comparative Effectiveness Review Disposition of Comments Report
Research Review Title: Interventions Targeting Sensory Challenges in Children With
Autism Spectrum Disorder (ASD)—An Update
Draft review ava…