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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47170/psn-pdf
    May 30, 2018 - Do written disclosures of serious events increase risk of malpractice claims? One health care system's experience. May 30, 2018 Painter LM, Kidwell KM, Kidwell RP, et al. Do Written Disclosures of Serious Events Increase Risk of Malpractice Claims? One Health Care System's Experience. J Patient Saf. 2018;14(2):87-9…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46910/psn-pdf
    January 23, 2019 - Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame. January 23, 2019 Armstrong N, Brewster L, Tarrant C, et al. Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for i…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45739/psn-pdf
    July 02, 2017 - High-risk medications in hospitalized elderly adults: are we making it easy to do the wrong thing? July 2, 2017 Blachman NL, Leipzig RM, Mazumdar M, et al. High-Risk Medications in Hospitalized Elderly Adults: Are We Making It Easy to Do the Wrong Thing? J Am Geriatr Soc. 2017;65(3):603-607. doi:10.1111/jgs.14703. …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44915/psn-pdf
    January 01, 2020 - Electronic health record adoption and rates of in-hospital adverse events. February 24, 2016 Furukawa MF, Eldridge N, Wang Y, et al. Electronic Health Record Adoption and Rates of In-hospital Adverse Events. J Patient Saf. 2020;16(2):137-142. doi:10.1097/pts.0000000000000257. https://psnet.ahrq.gov/issue/electroni…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38558/psn-pdf
    February 18, 2011 - Medication discrepancies upon hospital to skilled nursing facility transitions. February 18, 2011 Tjia J, Bonner A, Briesacher BA, et al. Medication discrepancies upon hospital to skilled nursing facility transitions. J Gen Intern Med. 2009;24(5):630-5. doi:10.1007/s11606-009-0948-2. https://psnet.ahrq.gov/issue/m…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40433/psn-pdf
    November 26, 2014 - Transitioning between electronic health records: effects on ambulatory prescribing safety. November 26, 2014 Abramson EL, Malhotra S, Fischer K, et al. Transitioning between electronic health records: effects on ambulatory prescribing safety. J Gen Intern Med. 2011;26(8):868-74. doi:10.1007/s11606-011-1703-z. http…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41298/psn-pdf
    November 27, 2012 - Patient safety culture and the association with safe resident care in nursing homes. November 27, 2012 Thomas KS, Hyer K, Castle NG, et al. Patient safety culture and the association with safe resident care in nursing homes. Gerontologist. 2012;52(6):802-811. doi:10.1093/geront/gns007. https://psnet.ahrq.gov/issue…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44710/psn-pdf
    May 09, 2017 - The vulnerabilities of computerized physician order entry systems: a qualitative study. May 9, 2017 Slight SP, Eguale T, Amato MG, et al. The vulnerabilities of computerized physician order entry systems: a qualitative study: Table 1. J Am Med Inform Assoc. 2015;23(2):311-316. doi:10.1093/jamia/ocv135. https://psn…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37843/psn-pdf
    March 04, 2011 - Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems. March 4, 2011 Tucker AL, Singer SJ, Hayes J, et al. Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems. Health Serv Res. 2008;43(5 Pt 2):1807…

  10. The Final Check: Say it Out Loud. | PSNet

    psnet.ahrq.gov/issue/final-check-say-it-out-loud
    July 31, 2023 - Multi-use Website The Final Check: Say it Out Loud. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL August 1, 2012 This Web site provides resources to help reduce incidence of …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36047/psn-pdf
    September 28, 2010 - When policy meets physiology: the challenge of reducing resident work hours. September 28, 2010 Lockley SW, Landrigan CP, Barger LK, et al. When policy meets physiology: the challenge of reducing resident work hours. Clin Orthop Relat Res. 2006;449:116-127. https://psnet.ahrq.gov/issue/when-policy-meets-physiology…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38760/psn-pdf
    July 08, 2009 - Nurses' perceptions of safety culture in long-term care settings. July 8, 2009 Wagner LM, Capezuti E, Rice JC. Nurses' perceptions of safety culture in long-term care settings. J Nurs Scholarsh. 2009;41(2):184-192. doi:10.1111/j.1547-5069.2009.01270.x. https://psnet.ahrq.gov/issue/nurses-perceptions-safety-culture…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60339/psn-pdf
    May 20, 2020 - We Want to Know-a mixed methods evaluation of a comprehensive program designed to detect and address patient-reported breakdowns in care. May 20, 2020 Fisher KA, Smith KM, Gallagher TH, et al. We Want to Know-a mixed methods evaluation of a comprehensive program designed to detect and address patient-reported brea…

  14. Ventilator-Associated Events and Outcome Measures Module | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/mvp/vae.html
    December 01, 2017 - Ventilator-Associated Events and Outcome Measures Module This module has tools and slide sets to help units accomplish three goals: Monitor ventilator-associated events and outcome measures. Reduce ventilator-associated events (VAE). Make evidence-based determinations about the care of ventilated patien…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37112/psn-pdf
    May 26, 2011 - The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study. May 26, 2011 Franklin BD, O'Grady K, Donyai P, et al. The impact of a closed-loop electronic prescribing and administration system on prescribing erro…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47760/psn-pdf
    February 06, 2019 - AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017. February 6, 2019 Rockville, MD: Agency for Healthcare Research and Quality; January 2019. https://psnet.ahrq.gov/issue/ahrq-national-scorecard-hospital-acquired-conditions-updated-baseline-rates- and-…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35875/psn-pdf
    May 21, 2013 - Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. May 21, 2013 The Joint Commission. https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person- surgery According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approxi…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852443/psn-pdf
    August 16, 2023 - Healthcare-associated infections in adult intensive care units: a multisource study examining nurses' safety attitudes, quality of care, missed care, and nurse staffing. August 16, 2023 Alanazi FK, Lapkin S, Molloy L, et al. Healthcare-associated infections in adult intensive care units: a multisource study examin…

  19. NICU Family Information Packet, Appendix B, Nephrocalcinosis (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-nephro.pdf
    June 02, 2025 - NICU Family Information Packet, Appendix B, Nephrocalcinosis Nephrocalcinosis Characteristics ■ Renal lithiasis in which calcium deposits form in the renal parenchyma and result in reduced kidney function and hematuria. ■ Seen with renal ultrasound, or occasionally on plain radiographs of the kidneys. ■ Resul…

  20. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/vae-tool.docx
    January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle AHRQ Safety Program for Mechanically Ventilated Patients Ventilator-Associated Event Data Collection Tool Date __________ Month __________ Hospital __________ Unit __________ Use this tool to track your progress i…
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