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psnet.ahrq.gov/node/46015/psn-pdf
August 15, 2018 - Patient mortality during unannounced accreditation
surveys at US hospitals.
August 15, 2018
Barnett ML, Olenski AR, Jena AB. Patient Mortality During Unannounced Accreditation Surveys at US
Hospitals. JAMA Intern Med. 2017;177(5):693-700. doi:10.1001/jamainternmed.2016.9685.
https://psnet.ahrq.gov/issue/patient-mo…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-229-section-6a-tables-4-5.pdf
June 02, 2025 - Section 6.A, Tables 4 and 4
Table 4: Percent Agreement and Kappa Statistics for Inter-Rater Reliability at Three Study Sites
Site Measure Numerator/
Eligibility Criteria
Number of Records
Reviewed
N Agreed (%) Kappa
Statistic
Hospital
#1
Timely Blood Culture 7 71% -0.17
Blood culture performed
at refer…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Tool_9_AdvisorTrain_508.pdf
March 06, 2013 - Strategy 1: Working with Patients & Families as Advisors (Tool 9)
Guide to Patient and Family Engagement
Patient and Family Advisor
Orientation Manual
Guide to Patient and Family Engagement
Table of Contents
About This Orientation Manual ..........................................................…
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/child-maltreatment-primary-care-interventions-november-2018
August 18, 2016 - burns, and other injuries with a high specificity for abuse
Visits to the emergency department
Hospitalizations
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www.ahrq.gov/news/newsroom/case-studies/ktcquips89.html
October 01, 2014 - Massachusetts Hospital Improves Medication Reconciliation With AHRQ Toolkit
Search All Impact Case Studies
March 2012
After participating in AHRQ-sponsored learning sessions and provider support calls, Masspro, the Massachusetts Quality Improvement Organization (QIO), worked with New England Rehabilitation …
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www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/sampleagenda.html
March 01, 2013 - Re-Engineered Discharge (RED) Toolkit
Tool 2: How to Begin the Re-engineered Discharge Implementation At Your Hospital (continued)
Previous Page Next Page
Table of Contents
Re-Engineered Discharge (RED) Toolkit
Tool 1: Overview
Tool 2: How To Begin the Re-engineered Discharge Implementation at Y…
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www.ahrq.gov/patient-safety/patients-families/engagingfamilies/index.html
March 01, 2023 - Guide to Patient and Family Engagement in Hospital Quality and Safety
Research shows that when patients are engaged in their health care, it can lead to measurable improvements in safety and quality. To promote stronger engagement, the Agency for Healthcare Research and Quality (AHRQ) developed a guide to help…
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www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/sampleagenda.html
March 01, 2013 - Re-Engineered Discharge (RED) Toolkit
Tool 2: How to Begin the Re-engineered Discharge Implementation At Your Hospital (continued)
Previous Page Next Page
Table of Contents
Re-Engineered Discharge (RED) Toolkit
Tool 1: Overview
Tool 2: How To Begin the Re-engineered Discharge Implementation at Y…
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psnet.ahrq.gov/issue/girl-dies-during-restraint-hospital-already-criticized-problems
March 16, 2011 - Newspaper/Magazine Article
A girl dies during restraint at hospital already criticized for problems.
Citation Text:
A girl dies during restraint at hospital already criticized for problems. Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1
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psnet.ahrq.gov/issue/amendment-medical-care-availability-and-reduction-error-mcare-act
June 03, 2009 - Legislation/Case Law
An Amendment of the Medical Care Availability and Reduction of Error (Mcare) Act.
Citation Text:
An Amendment of the Medical Care Availability and Reduction of Error (Mcare) Act. Pennsylvania General Assembly.
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psnet.ahrq.gov/issue/patient-safety-initiative-hospital-executive-and-physician-leadership-strategies
November 27, 2018 - Toolkit
Patient Safety Initiative: Hospital Executive and Physician Leadership Strategies.
Citation Text:
Patient Safety Initiative: Hospital Executive and Physician Leadership Strategies. Oakbrook, IL: Joint Commission Resources; January 2014.
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psnet.ahrq.gov/issue/hsmr-new-approach-measuring-hospital-mortality-trends-canada
June 22, 2015 - Book/Report
HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada.
Citation Text:
HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada. Ottowa, Ontario, CA: Canadian Institute for Health Information; 2007. ISBN 9781554651832.
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www.ahrq.gov/news/newsroom/case-studies/201504.html
March 01, 2015 - Buffalo Hospital Uses TeamSTEPPS® to Improve Pediatric Patient Safety
Search All Impact Case Studies
March 2015
Women and Children's Hospital of Buffalo, the only pediatric facility in Western New York, has used an AHRQ-designed patient safety program to improve care for children with bronchiolitis. Hospita…
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www.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety-biosketches.html
September 01, 2016 - Bindman helped to establish the association between access to care and preventable hospitalizations for
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psnet.ahrq.gov/issue/adoption-technology-improve-medication-safety-perspectives-pharmacy-directors
February 15, 2011 - Study
Adoption of technology to improve medication safety: perspectives of pharmacy directors.
Citation Text:
Bussard BE, McAlearney AS, Pedersen CA, et al. Adoption of Technology to Improve Medication Safety. J Patient Saf. 2008;2(4). doi:10.1097/01.jps.0000236914.48955.99.
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psnet.ahrq.gov/issue/role-chief-executive-officer-maximizing-patient-safety
January 03, 2017 - Newspaper/Magazine Article
The role of the chief executive officer in maximizing patient safety.
Citation Text:
Shorr AS. The role of the chief executive officer in maximizing patient safety. Healthcare executive. 2007;22(2):20-2, 24, 26.
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Format:
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www.ahrq.gov/patient-safety/patients-families/engagingfamilies/strategy4/index.html
December 01, 2017 - Strategy 4: Care Transitions From Hospital to Home: IDEAL Discharge Planning
Research shows that when patients are engaged in their health care, it can lead to measurable improvements in safety and quality. To promote stronger engagement, Agency for Healthcare Research and Quality developed the Guide to Patient…
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psnet.ahrq.gov/issue/when-errors-occur
March 12, 2011 - Newspaper/Magazine Article
When errors occur.
Citation Text:
Wetzel TG. When errors occur, 'I'm sorry' is a big step, but just the first. Hospitals & health networks. 2010;84(10):41-2, 44, 2.
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psnet.ahrq.gov/web-mm/check-wristband
August 03, 2009 - Trends in maternal mortality and severe maternal morbidity during delivery-related hospitalizations
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psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
November 15, 2023 - Lorazepam was likely selected for this patient because it had been utilized to treat anxiety during prior hospitalizations