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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45563/psn-pdfOctober 19, 2016 - Using a change model to reduce the risk of surgical site infection. October 19, 2016 Burden M. Using a change model to reduce the risk of surgical site infection. Br J Nurs. 2016;25(17):949- 955. https://psnet.ahrq.gov/issue/using-change-model-reduce-risk-surgical-site-infection Surgical site infections can resul… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46579/psn-pdfApril 11, 2018 - Electronic medicine can send you test results quickly. But what if they're scary? April 11, 2018 Boodman SG. Washington Post. March 26, 2018. https://psnet.ahrq.gov/issue/electronic-medicine-can-send-you-test-results-quickly-what-if-theyre-scary Although providing patients with access to physician notes and test r… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45772/psn-pdfJanuary 11, 2017 - Technical Series on Safer Primary Care. January 11, 2017 Geneva, Switzerland: World Health Organization; 2016. https://psnet.ahrq.gov/issue/technical-series-safer-primary-care Much of patient safety research has focused on the hospital setting, but a majority of health care is delivered in the ambulatory setting. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45570/psn-pdfDecember 07, 2016 - Getting the Board on Board: What Your Board Needs to Know About Quality and Safety, Third Edition. December 7, 2016 Oak Brook, IL; Joint Commission; 2016. ISBN: 9781599409412. https://psnet.ahrq.gov/issue/getting-board-board-what-your-board-needs-know-about-quality-and-safety- third-edition Engaging hospital lead… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60235/psn-pdfApril 15, 2020 - Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust. April 15, 2020 NHS Improvement. Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust. NHS England. March 2020. https://psnet.ahrq.gov/issue/independent-morta… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37294/psn-pdfMay 21, 2013 - Improving Hand-Off Communication. May 21, 2013 Oakbrook Terrace lL: Joint Commission Resources; 2007. ISBN 9781599400907. https://psnet.ahrq.gov/issue/improving-hand-communication The process of transferring primary responsibility for patient care is commonly referred to as a handoff. Handoffs are inherently dange… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47568/psn-pdfMarch 06, 2019 - Trends in anesthesia-related liability and lessons learned. March 6, 2019 Mora JC, Kaye AD, Romankowski ML, et al. Trends in Anesthesia-Related Liability and Lessons Learned. Adv Anesth. 2018;36(1):231-249. doi:10.1016/j.aan.2018.07.009. https://psnet.ahrq.gov/issue/trends-anesthesia-related-liability-and-lessons-l… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/865704/psn-pdfMay 01, 2024 - Supporting error management and safety climate in ambulatory care practices: the CIRSforte study. May 1, 2024 Müller BS, Lüttel D, Schütze D, et al. Supporting error management and safety climate in ambulatory care practices: the CIRSforte study. J Patient Saf. 2024;20(5):314-322. doi:10.1097/pts.0000000000001225. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/854835/psn-pdfOctober 25, 2023 - Improving patient safety by shifting power from health professionals to patients. October 25, 2023 BMJ. 2023(383):2219, 2278, 2319, 2331. https://psnet.ahrq.gov/issue/improving-patient-safety-shifting-power-health-professionals-patients This compendium of editorials and opinion pieces discuss “Martha’s Rule,” a ne… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44314/psn-pdfNovember 06, 2015 - Unintentional discontinuation of chronic medications for seniors in nursing homes: evaluation of a national medication reconciliation accreditation requirement using a population-based cohort study. November 6, 2015 Stall NM, Fischer HD, Wu F, et al. Unintentional Discontinuation of Chronic Medications for Seniors… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/851361/psn-pdfJuly 12, 2023 - Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta- analysis. July 12, 2023 Wilson C, Janes G, Lawton R, et al. Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta-analysis. BMJ Qual Saf. 2023;32(10):573-588. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41643/psn-pdfSeptember 05, 2012 - A Randomized Field Study of a Leadership WalkRounds- Based Intervention. September 5, 2012 Tucker AL, Singer SJ. Cambridge, MA: Harvard Business School; June 25, 2012. HBS Working Paper No. 12-113. https://psnet.ahrq.gov/issue/randomized-field-study-leadership-walkrounds-based-intervention Leadership WalkRounds h… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38157/psn-pdfOctober 22, 2008 - Contributing factors identified by hospital incident report narratives. October 22, 2008 Nuckols TK, Bell DS, Paddock SM, et al. Contributing factors identified by hospital incident report narratives. Qual Saf Health Care. 2008;17(5):368-72. doi:10.1136/qshc.2007.023721. https://psnet.ahrq.gov/issue/contributing-f… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46844/psn-pdfMarch 07, 2018 - Learning collaboratives: insights and a new taxonomy from AHRQ's two decades of experience. March 7, 2018 Nix M, McNamara P, Genevro J, et al. Learning Collaboratives: Insights And A New Taxonomy From AHRQ's Two Decades Of Experience. Health Aff (Millwood). 2018;37(2):205-212. doi:10.1377/hlthaff.2017.1144. https… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35218/psn-pdfAugust 07, 2018 - Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety. August 7, 2018 Scobie S, Thomson R. London, UK : National Patient Safety Agency; 2005. https://psnet.ahrq.gov/issue/building-memory-preventing-harm-reducing-risks-and-improving-patient-safety Created in 2001 to institute changes in he… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837848/psn-pdfAugust 17, 2022 - Health care quality and safety in a correctional system: creating goals and performance measures for improvement. August 17, 2022 Neely J, Sampath R, Kirkbride G, et al. Health care quality and safety in a correctional system: creating goals and performance measures for improvement. J Correct Health Care. 2022;28(… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35220/psn-pdfMay 14, 2015 - Patient Safety and Quality Improvement Act of 2005. May 14, 2015 Pub L No. 109-41. https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005 This bill amends the Public Health Service Act to encourage a culture of safety in health care organizations. The bill, signed into law July 29, 2005… -
psnet.ahrq.gov/perspective/ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safetyAugust 31, 2020 - In addition to possible setbacks in progress toward improved antibiotic stewardship, these practices
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866848/psn-pdfSeptember 25, 2024 - In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement September 25, 2024 Thomas E, Mossburg S, Lee M. In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement. … -
Spotlight (pdf file)
psnet.ahrq.gov/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdfJanuary 01, 2019 - Spotlight Spotlight "Do You Want Everything Done?": Clarifying Code Status Source and Credits • This presentation is based on the December 2019 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Karl Steinberg MD, CMD, HMDC & Thaddeus M…
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