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psnet.ahrq.gov/node/42711/psn-pdf
October 31, 2014 - Characterising the complexity of medication safety using
a human factors approach: an observational study in two
intensive care units.
October 31, 2014
Carayon P, Wetterneck TB, Cartmill R, et al. Characterising the complexity of medication safety using a
human factors approach: an observational study in two inten…
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psnet.ahrq.gov/node/44004/psn-pdf
September 01, 2016 - Impact of computerized physician order entry alerts on
prescribing in older patients.
September 1, 2016
Lester PE, Rios-Rojas L, Islam S, et al. Impact of computerized physician order entry alerts on prescribing
in older patients. Drugs Aging. 2015;32(3):227-33. doi:10.1007/s40266-015-0244-2.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/44372/psn-pdf
June 21, 2016 - Hospital characteristics associated with penalties in the
Centers for Medicare & Medicaid Services Hospital-
Acquired Condition Reduction Program.
June 21, 2016
Rajaram R, Chung JW, Kinnier C, et al. Hospital Characteristics Associated With Penalties in the Centers
for Medicare & Medicaid Services Hospital-Acquire…
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psnet.ahrq.gov/node/36366/psn-pdf
April 11, 2011 - Adverse events in the neonatal intensive care unit:
development, testing, and findings of an NICU-focused
trigger tool to identify harm in North American NICUs.
April 11, 2011
Sharek PJ, Horbar JD, Mason W, et al. Adverse events in the neonatal intensive care unit: development,
testing, and findings of an NICU-foc…
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psnet.ahrq.gov/node/39662/psn-pdf
April 30, 2014 - Patient record review of the incidence, consequences,
and causes of diagnostic adverse events.
April 30, 2014
Zwaan L, de Bruijne M, Wagner C, et al. Patient record review of the incidence, consequences, and causes
of diagnostic adverse events. Arch Intern Med. 2010;170(12):1015-21.
doi:10.1001/archinternmed.2010.…
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psnet.ahrq.gov/node/39641/psn-pdf
September 20, 2011 - Adherence to Surgical Care Improvement Project
measures and the association with postoperative
infections.
September 20, 2011
Stulberg JJ, Delaney CP, Neuhauser D, et al. Adherence to surgical care improvement project measures
and the association with postoperative infections. JAMA. 2010;303(24):2479-85.
doi:10.1…
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psnet.ahrq.gov/node/44056/psn-pdf
May 19, 2018 - Impact of inpatient harms on hospital finances and
patient clinical outcomes.
May 19, 2018
Adler L, Yi D, Li M, et al. Impact of Inpatient Harms on Hospital Finances and Patient Clinical Outcomes. J
Patient Saf. 2018;14(2):67-73. doi:10.1097/PTS.0000000000000171.
https://psnet.ahrq.gov/issue/impact-inpatient-harms…
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psnet.ahrq.gov/node/43729/psn-pdf
November 21, 2017 - Medical harm: patient perceptions and follow-up actions.
November 21, 2017
Lyu HG, Cooper M, Mayer-Blackwell B, et al. Medical Harm: Patient Perceptions and Follow-up Actions. J
Patient Saf. 2017;13(4):199-201. doi:10.1097/PTS.0000000000000136.
https://psnet.ahrq.gov/issue/medical-harm-patient-perceptions-and-follo…
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psnet.ahrq.gov/node/41283/psn-pdf
April 11, 2012 - Clinical diagnoses and autopsy findings: discrepancies in
critically ill patients.
April 11, 2012
Tejerina E, Esteban A, Fernández-Segoviano P, et al. Clinical diagnoses and autopsy findings:
discrepancies in critically ill patients*. Crit Care Med. 2012;40(3):842-6.
doi:10.1097/CCM.0b013e318236f64f.
https://psne…
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psnet.ahrq.gov/node/45555/psn-pdf
June 15, 2017 - Variations in GPs' decisions to investigate suspected
lung cancer: a factorial experiment using multimedia
vignettes.
June 15, 2017
Sheringham J, Sequeira R, Myles J, et al. Variations in GPs' decisions to investigate suspected lung
cancer: a factorial experiment using multimedia vignettes. BMJ Qual Saf. 2017;26(6…
-
psnet.ahrq.gov/node/47671/psn-pdf
January 01, 2019 - Racial, ethnic, and socioeconomic disparities in patient
safety events for hospitalized children.
December 19, 2018
Stockwell DC, Landrigan CP, Toomey SL, et al. Racial, Ethnic, and Socioeconomic Disparities in Patient
Safety Events for Hospitalized Children. Hosp Pediatr. 2019;9(1):1-5. doi:10.1542/hpeds.2018-0131…
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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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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/multi-vari-chart
January 01, 2023 - Multi-Vari Chart
Also Known As
Multivariate chart
Description
A multi-vari chart shows both several sources of variation in addition to the most significant contributors to total variation.
Uses
When the output has a variable measurement.
When attempting to identify the biggest…
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www.ahrq.gov/hai/tools/cauti-hospitals/toolkit-about.html
March 01, 2018 - About the Toolkit Development
Toolkit for Reducing CAUTI in Hospitals
The toolkit was developed as part of a national implementation project to reduce CAUTI in hospitals. The 4-year project brought together subject matter experts and participating hospitals across the country.
Background
Catheter-associ…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-ger.pdf
June 02, 2025 - NICU Family Information Packet, Appendix B, Gastroesophageal Reflux
Gastroesophageal Reflux
Characteristics
■ Common problem in premature infants.
– Lower esophageal sphincter hypotonia.
– Transient relaxation of the esophageal sphincter.
– Less frequent esophageal peristaltic activity.
– Delayed gastric em…
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK1_T5-Sample_Policy_Letter_final.docx
October 01, 2016 - Nursing Home
Antimicrobial Stewardship Guide
Help Clinicians Choose the Right Antibiotic
Toolkit 1. Working With a Lab To Improve Antibiotic Prescribing
Tool 5. Sample Policy Letter
[NAME OF NURSING HOME]
RE: Antibiogram Policy
[DATE]
Antibiotics are among the most commonly prescribed pharmaceuticals in long-term car…
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK1_T5-Sample_Policy_Letter_final.pdf
October 01, 2016 - Nursing Home
Antimicrobial Stewardship Guide
Help Clinicians Choose the Right Antibiotic
Toolkit 1. Working With a Lab To Improve Antibiotic Prescribing
[DATE]
Tool 5. Sample Policy Letter
[NAME OF NURSING HOME]
RE: Antibiogram Policy
[DATE]
Antibiotics are among the most commonly prescribed pharmaceuti…
-
www.ahrq.gov/research/findings/final-reports/stpra/stpraexh10.html
April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Exhibit 10. Probability variations used in the sensitivity analyses
Previous Page Next Page
Table of Contents
Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Executive Summary
Ch…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb21.html
December 01, 2017 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Appendix B21: Facts and Flow Chart
Previous Page Next Page
Table of Contents
The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Chapter 1. Introduction and Program Overview
Ch…
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hcup-us.ahrq.gov/reports/methods/2005-07.pdf
January 01, 2005 - Calculating Variances Using the 1999 Nationwide Inpatient Sample
HCUP Methods Series
kbr33831
Contact Information:
Healthcare Cost and Utilization Project (HCUP)
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
http://www.hcup-us.ahrq.gov
For Technical Assistance wit…