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  1. Missed Nursing Care: A Key Measure for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
    March 01, 2018 - One example would be care bundles for central line infection prevention. … And these differences line up very closely to the variation across hospitals in mortality, infection … Readmissions, infection rates, never events like poor glycemic control—they're all directly related to

  2. Voluntary electronic reporting of medical errors and adverse events. | PSNet

    psnet.ahrq.gov/issue/voluntary-electronic-reporting-medical-errors-and-adverse-events
    March 21, 2017 - Study Voluntary electronic reporting of medical errors and adverse events. Citation Text: Milch CE, Salem D, Pauker SG, et al. Voluntary electronic reporting of medical errors and adverse events. An analysis of 92,547 reports from 26 acute care hospitals. J Gen Intern Med. 2006;21(2):1…

  3. Hospital board oversight of quality and patient safety: a narrative review and synthesis of recent empirical research. | PSNet

    psnet.ahrq.gov/issue/hospital-board-oversight-quality-and-patient-safety-narrative-review-and-synthesis-recent
    November 13, 2019 - Review Classic Hospital board oversight of quality and patient safety: a narrative review and synthesis of recent empirical research. Citation Text: Millar R, Mannion R, Freeman T, et al. Hospital board oversight of quality and patient safety: a narrative review…

  4. Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group study. | PSNet

    psnet.ahrq.gov/issue/identifying-understanding-and-overcoming-barriers-medication-error-reporting-hospitals-focus
    March 13, 2015 - Study Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group study. Citation Text: Hartnell N, MacKinnon NJ, Sketris I, et al. Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus gr…

  5. Risk of medication safety incidents with antibiotic use measured by defined daily doses. | PSNet

    psnet.ahrq.gov/issue/risk-medication-safety-incidents-antibiotic-use-measured-defined-daily-doses
    July 06, 2022 - Study Risk of medication safety incidents with antibiotic use measured by defined daily doses. Citation Text: Hamad A, Cavell G, Wade P, et al. Risk of medication safety incidents with antibiotic use measured by defined daily doses. Int J Clin Pharm. 2013;35(5):772-9. doi:10.1007/s11096…

  6. Internal reporting system to improve a pharmacy's medication distribution process. | PSNet

    psnet.ahrq.gov/issue/internal-reporting-system-improve-pharmacys-medication-distribution-process
    October 31, 2017 - Study Internal reporting system to improve a pharmacy's medication distribution process. Citation Text: Rickrode GA, Williams-Lowe ME, Rippe JL, et al. Internal reporting system to improve a pharmacy's medication distribution process. Am J Health Syst Pharm. 2007;64(11):1197-202. Cop…

  7. Frequency of HIV-related medication errors and associated risk factors in hospitalized patients. | PSNet

    psnet.ahrq.gov/issue/frequency-hiv-related-medication-errors-and-associated-risk-factors-hospitalized-patients
    April 24, 2018 - Study Frequency of HIV-related medication errors and associated risk factors in hospitalized patients. Citation Text: Pastakia SD, Corbett AH, Raasch RH, et al. Frequency of HIV-related medication errors and associated risk factors in hospitalized patients. Ann Pharmacother. 2008;42(4)…

  8. Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/understanding-attitudes-hospital-pharmacists-reporting-medication-incidents-qualitative-study
    September 04, 2016 - Study Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study. Citation Text: Williams SD, Phipps D, Ashcroft DM. Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study. Res Social Adm…

  9. Microsoft Word - ehcrr#2toCSI.doc (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/atypical-antipsychotics-seniors-death_research.pdf
    August 01, 2007 - this magnitude of risk in perspective, all measured health conditions except heart failure and HIV infection … which its Public Health Advisory was based, heart- related events (heart failure, sudden death) and infections … .0001 Other cardiovascular disorders 4075 16.7% 2609 20.3% 1.3 <.0001 Cancer 0 0.0% 0 0.0% - - HIV infection … diabetes, myocardial infarction, other ischemic heart disease, other cardiovascular disorders, cancer, HIV infection

  10. Facilitator Guide: Optimize Your Briefings and Debriefings (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings_facnotes.docx
    December 01, 2017 - Evidence supports that addressing cultural issues in conjunction with the technical work improves infection … Briefings and debriefings can improve communication and teamwork; reduce complications like surgical site infections … SAY: Include your surgical site infection intervention bundle on your briefing checklist. … Review those defects with your CUSP team or a surgical site infection quality improvement team.

  11. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication | PSNet

    psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
    August 01, 2012 - time period for ascertainment. 11,14,17,18 The most common complications are wound problems such as infection … or gastric wall ulceration, 6,11,14 tube dislodgement with peritonitis or necrotizing soft tissue infection … When the PEG tube has complications, such as a skin or soft tissue infection, but feeding access is still

  12. Medical Injury Identification Using Hospital Discharge Data (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Layde.pdf
    January 01, 2003 - most focus on relatively few types of reportable events, such as adverse drug events or nosocomial infections … of ascertainment of adverse events is the Centers for Disease Control’s (CDC) National Nosocomial Infection … Surveillance System, which is based on reports from hospital infection control practitioners, who … complications 3,771 6.8 1.14*** Nervous system comp 1,489 2.7 1.37*** GU complications 1,956 3.5 0.86*** Infection

  13. Overview of Hospital Stays Among Children and Adolescents, 2019 (pdf file)

    hcup-us.ahrq.gov/reports/statbriefs/sb299-Hospital-Stays-Children-2019.pdf
    January 01, 2019 - Short gestation; low birth weight; and fetal growth retardation 6 0.4 Perinatal infections … 3.9 6 2.5 Fluid and electrolyte disorders 6 3.8 Other specified upper respiratory infections … 7 3.7 Skin and subcutaneous tissue infections 8 3.5 6 2.7 Encounter … for antineoplastic therapies 9 2.6 5 3.4 6 3.6 8 2.3 Intestinal infection 10 2.4

  14. Diabetes-Related Inpatient Stays, 2018 (pdf file)

    hcup-us.ahrq.gov/reports/statbriefs/sb279-Diabetes-Inpatient-Stays-2018.pdf
    January 01, 2018 - ranked in the top 10 most common principal diagnoses for type 1 but not type 2 diabetes: urinary tract infections … , skin/subcutaneous tissue infection, fluid and electrolyte disorders, and chronic kidney disease. … atherosclerosis* —† —† 8 29.3 Acute/unspecified renal failure 2 29.3 9 28.6 Skin/subcutaneous tissue infections … nonpressure ulcer of skin, coronary atherosclerosis and other heart disease, and skin/subcutaneous tissue infections

  15. Effectiveness of Treatments for Diabetic Peripheral Neuropathy (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/diabetic-neuropathy_research-protocol.pdf
    May 09, 2016 - (since injuries are not noticed by the patient immediately) as well as foot and leg ulceration and infections … Recurrent ulcers and infections may eventually lead to amputation of the lower extremities. … sensation increases risk for foot injury, delays treatment and can lead to foot and leg ulceration and infections … Ulcers and infections may eventually lead to amputation of the lower extremities.

  16. Microsoft Word - NHDR6-HCUPMethodsReport v7.doc (pdf file)

    hcup-us.ahrq.gov/reports/methods/2008_06.pdf
    January 01, 2008 - PSI 7 Selected infections due to medical care per 1,000 medical and surgical discharges (excluding immunocompromised … and cancer patients, stays under 2 days, and admissions specifically for such infections*), age 18 … years or older or obstetric admissions * Also excludes admissions specifically for such infections … 1,000 elective-surgery discharges with an operating room procedure (excluding patients admitted for infection … & MISC METABOLIC DISORDERS AGE >17 W CC 390,433 1.0 392,250 1.0 320: KIDNEY & URINARY TRACT INFECTIONS

  17. Acute Renal Failure Hospitalizations, 2005-2014 #231

    hcup-us.ahrq.gov/reports/statbriefs/sb231-Acute-Renal-Failure-Hospitalizations.jsp
    November 01, 2017 - Respiratory failure; insufficiency; arrest 6 42,400 3.2 8 88,200 2.4 108.0 Urinary tract infections … congestive heart failure, acute myocardial infarction, dysrhythmias, and coronary atherosclerosis) and two infections … (pneumonia and urinary tract infections). … Urinary tract infections—acute renal failure: $8,500; no acute renal failure: $6,400; % higher costs

  18. The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis | PSNet

    psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
    February 26, 2025 - humidification by switching from passive heat and moisture exchangers, deployed initially because of their infection … Clinical protocols and practices were revised to prioritize infection control for healthcare workers.

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49693/psn-pdf
    October 01, 2013 - communities in the US are among the groups at highest risk for human immunodeficiency virus (HIV) infection … .(13) In 2009, the rate of newly identified HIV infection was 2.6% among transgender persons, compared

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49871/psn-pdf
    August 10, 2019 - of bladder decompensation including a large postvoid residual volume, which can also predispose to infection … A urinalysis would have been helpful to assess for the presence of infection or hematuria.(1,4) As
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