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81. Is my patient ready for a safe transfer to a lower-intensity care setting? Nursing complexity as an independent predictor of adverse events risk after ICU discharge. | PSNet
    psnet.ahrq.gov/issue/my-patient-ready-safe-transfer-lower-intensity-care-setting-nursing-complexity-independent
    April 26, 2023 - In this 13-bed ICU, researchers found that various factors including level of acuity and nursing complexity … January 23, 2019 Effects of a multimodal program including simulation on job strain among

82. Measuring safety in older adult care homes: a scoping review of the international literature. | PSNet
    psnet.ahrq.gov/issue/measuring-safety-older-adult-care-homes-scoping-review-international-literature
    June 30, 2021 - available safety measures used for quality monitoring and improvement in older adult care homes, including … Quality standards for safe medication in nursing homes: development through a multistep approach including

83. Economic evaluations of interventions to prevent and control health-care-associated infections: a systematic review. | PSNet
    psnet.ahrq.gov/issue/economic-evaluations-interventions-prevent-and-control-health-care-associated-infections
    May 18, 2022 - This systematic review including 67 studies identified several cost-effective interventions addressing … health care-associated infections, including screening high-risk individuals, universal decolonization

84. The effect of a transitional pharmaceutical care program on the occurrence of ADEs after discharge from hospital in patients with polypharmacy. | PSNet
    psnet.ahrq.gov/issue/effect-transitional-pharmaceutical-care-program-occurrence-ades-after-discharge-hospital
    September 08, 2021 - This multi-center study found that a transitional pharmacy care program (including teach-back, pharmacy … Duplicate Therapies in Retail Pharmacy March 15, 2023 Including

85. Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study. | PSNet
    psnet.ahrq.gov/issue/prevalence-and-characterisation-diagnostic-error-among-7-day-all-cause-hospital-medicine
    April 12, 2023 - These diagnostic errors were primarily related to clinician diagnostic reasoning , including failure … The majority of the diagnostic errors resulted in some form of clinical impact, including short-term

86. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/37852/psn-pdf
    May 02, 2018 - Benefits and risks of including patients on RCA teams. May 2, 2018 ISMP Medication Safety Alert! … https://psnet.ahrq.gov/issue/benefits-and-risks-including-patients-rca-teams This article describes … https://psnet.ahrq.gov/issue/benefits-and-risks-including-patients-rca-teams

87. Systemic failures in nursing home care--a scoping study. | PSNet
    psnet.ahrq.gov/issue/systemic-failures-nursing-home-care-scoping-study
    July 17, 2013 - This scoping review including 38 articles identified 29 systemic issues faced by nursing homes, including

88. Hospital process compliance and surgical outcomes in Medicare beneficiaries. | PSNet
    psnet.ahrq.gov/issue/hospital-process-compliance-and-surgical-outcomes-medicare-beneficiaries
    May 01, 2015 - Hospitals are now required to report adherence to measures intended to prevent post-surgical complications, including … These measures are being publicly reported by groups including the Centers for Medicare and Medicaid

89. Power of saying ‘I Don’t Know’: psychological safety and participatory strategies for healthcare leaders. | PSNet
    psnet.ahrq.gov/issue/power-saying-i-dont-know-psychological-safety-and-participatory-strategies-healthcare-leaders
    August 31, 2011 - Psychological safety is critical for all staff in health systems, including leadership. … to acknowledge their limitations, as this creates a culture of trust and enables innovation by including

90. Advances in the Prevention and Control of HAIs. | PSNet
    psnet.ahrq.gov/issue/advances-prevention-and-control-hais
    August 20, 2018 - This AHRQ publication offers 19 papers that explore government-funded research into HAIs, including lessons … The report discusses specific infections, including clostridium difficile and methicillin-resistant staphylococcus

91. Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans | PSNet
    psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-customized-prevention
    July 23, 2024 - Access to Fall TIPS resources Fall TIPS training and retraining for nursing and non-nursing staff, including … Patients are particularly vulnerable to falling while in the hospital due to a number of factors, including … six most common reasons patients in hospitals fall: the patient fall history, high-risk conditions (including … Including the input of people who know the patient best allows for greater customization. … Outreach and education on the program should reach various hospital groups, including the Quality and

92. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/862614/psn-pdf
    February 14, 2024 - This scoping review including 38 articles identified 29 systemic issues faced by nursing homes, including

93. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33596/psn-pdf
    June 01, 2025 - As with many key concepts in patient safety, this one began with work outside of health care, including … In the late 1980s, early leaders in patient safety in anesthesiology, including Gaba and Runciman, adapted … Staffing levels and education, including establishing appropriate minimum physician and nurse staffing … Surveillance, communication, and electronic monitoring, including patient-centric communication styles … Timely reaction and response to deteriorating patients, including implementing agreed response times

94. CE/MOC Quizzes | PSNet
    psnet.ahrq.gov/cme
    February 26, 2025 - was initially stable upon arrival, though with signs of fluid overload and electrolyte abnormalities including … Despite treatment including heparin, amiodarone, and metoprolol for atrial fibrillation, and interventions … Three weeks later, he presented with ongoing symptoms including worsening cognition and increased headache … Contributes to Permanent Paralysis A 38-year-old man sustained multiple injuries in a motorcycle crash, including … was discharged with antibiotic prescriptions, but returned three days later with worsening symptoms, including

95. Medication errors in acute cardiovascular and stroke patients. A scientific statement from the American Heart Association. | PSNet
    psnet.ahrq.gov/issue/medication-errors-acute-cardiovascular-and-stroke-patients-scientific-statement-american
    February 03, 2011 - from the American Heart Association reviews the specific types of medication errors in these patients, including … specific, evidence-based recommendations for preventing medication errors in this patient population, including

96. Changing the "working while sick" culture. | PSNet
    psnet.ahrq.gov/issue/changing-working-while-sick-culture
    March 14, 2018 - Clinicians often feel pressured to work while sick or fatigued because of cultural and system factors, including … The authors recommend strategies and policies to address this problem, including promoting professionalism

97. Safety at the time of the COVID-19 pandemic: how to keep our oncology patients and healthcare workers safe. | PSNet
    psnet.ahrq.gov/issue/safety-time-covid-19-pandemic-how-keep-our-oncology-patients-and-healthcare-workers-safe
    September 03, 2011 - The authors recommend several approaches ensure patient safety, including COVID-19 prescreening/screening … They also propose measures focused on healthcare worker safety, including appropriate use of personal

98. Information transfer and communication in surgery: a systematic review. | PSNet
    psnet.ahrq.gov/issue/information-transfer-and-communication-surgery-systematic-review
    September 26, 2012 - systematic review of 38 published studies identified communication failures in all phases of surgical care, including … A number of interventions have been proposed to address this issue, including standardized checklists

99. A comparative review of patient safety initiatives for national health information technology. | PSNet
    psnet.ahrq.gov/issue/comparative-review-patient-safety-initiatives-national-health-information-technology
    November 03, 2015 - This review explores patient safety initiatives for health IT systems across six countries, including … Significant gaps in health IT safety initiatives were identified, including inadequate regulatory oversight

100. Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. | PSNet
     psnet.ahrq.gov/issue/improving-situation-awareness-reduce-unrecognized-clinical-deterioration-and-serious-safety
     December 02, 2014 - The team utilized a number of overlapping interventions, including proactive risk identification, frequent … 12, 2016 Successful implementation of standardized multidisciplinary bedside rounds, including