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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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.…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. 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…
  13. 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…
  14. 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…
  15. 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…
  16. 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…
  17. 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…
  18. 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…
  19. 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…
  20. 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…