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6141. An engineered solution to the maladministration of spinal injections. | PSNet
      psnet.ahrq.gov/issue/engineered-solution-maladministration-spinal-injections
      March 14, 2022 - Study An engineered solution to the maladministration of spinal injections. Citation Text: Lawton R, Gardner P, Green B, et al. An engineered solution to the maladministration of spinal injections. Qual Saf Health Care. 2009;18(6):492-5. doi:10.1136/qshc.2007.025767. Copy Citation …

6142. Has the pendulum swung too far?; The impact of missed abdominal injuries in the era of nonoperative management. | PSNet
      psnet.ahrq.gov/issue/has-pendulum-swung-too-far-impact-missed-abdominal-injuries-era-nonoperative-management
      August 04, 2021 - Study Has the pendulum swung too far?; The impact of missed abdominal injuries in the era of nonoperative management. Citation Text: Fairfax LM, Christmas B, Deaugustinis M, et al. Has the pendulum swung too far? The impact of missed abdominal injuries in the era of nonoperative manage…

6143. Safe Medication Administration: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/safe-medication-fac-guide.html
      July 01, 2023 - Safe Medication Administration: Facilitator Guide AHRQ Safety Program for Perinatal Care Slide 1: Safe Medication Administration Say: The Safe Medication Administration bundle provides information on high-alert medications commonly used in labor and delivery (L&D) units, and discusses the importance of …

6144. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/866419
      March 27, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Artificial Intelligence: System-Level Considerations Curated Library Foundations Generative artificial intelligence, patient safety and healthcare quality: a review. Howell MD. BMJ Qual Saf. 2024;33:748-754. Artificial intelligence (AI) is…

6145. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33583/psn-pdf
      March 01, 2023 - Simulation Training March 1, 2023 Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/simulation-training Originally published in 2014 by researchers at the University of California, San Francisco. Updated in March 2023, by Jennifer J. Edwards, MS, RN, CHSE…

6146. Root Cause Analysis Gone Wrong | PSNet
      psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
      August 28, 2024 - Root Cause Analysis Gone Wrong Citation Text: Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…

6147. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49531/psn-pdf
      March 01, 2007 - Failure to Report March 1, 2007 Spath P. Failure to Report. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/failure-report Case Objectives List common causes of medical errors. Appreciate the magnitude of underreporting of adverse events. List the common barriers to reporting adverse events and near misses…

6148. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49829/psn-pdf
      May 01, 2018 - Root Cause Analysis Gone Wrong May 1, 2018 Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney transplant. A suitabl…

6149. Transcript: How To Address Attitudes and Beliefs Around Infection Prevention Strategies and Techniques (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/attitudes-beliefs-transcript.pdf
      April 01, 2022 - Transcript: How To Address Attitudes and Beliefs Around Infection Prevention Strategies and Techniques AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI Transcript How To Address Attitudes and Beliefs Around Infection Prevention Strategies and Techniques Host: Kate Schmidgall …

6150. Rapidresponse Facguide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse_facguide.docx
      May 01, 2017 - AHRQ Safety Program for Perinatal Care Rapid Response for Perinatal Safety Rapid Response for Perinatal Safety SAY: The Rapid Response for Perinatal Safety bundle provides information establishing a unitwide approach, also referred to as a rapid response system, for responding to urgent maternity care issues. Slide …

6151. How PSOs Help Health Care Organizations Improve Patient Safety Culture (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-patient-safety-culture-brief.pdf
      September 01, 2016 - How PSOs Help Health Care Organizations Improve Patient Safety Culture How PSOs Help Health Care Organizations Improve Patient Safety Culture Developing a culture of safety is an essential task for health care organizations as they strive to eliminate the factors that contribute to medical errors, patient harm, …

6152. 025-Ss-Why-Choose-Cusp-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/025-ss-why-choose-cusp-fg.docx
      April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI Why Choose a CUSP Approach? Surgical Services Slide Title and Commentary Slide Number and Slide Why Choose a CUSP Approach? SAY: Welcome to this presentation titled “Why Choose a CUSP Approach?” CUSP is short for the “Comprehensive Unit-based Safety Program.” …

6153. Plan-Do-Study-Act Worksheet (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/pdsa-worksheet.pdf
      June 02, 2025 - Plan-Do-Study-Act Worksheet PDSA Worksheet Page 1 of 2 PDSA Worksheet Complete Page 1 of the worksheet when planning your Plan-Do-Study-Act (PDSA) cycle. Multiple PDSAs can be designed in support of a single Aim. AIM STATEMENT (Measurable goal, with a target date) __________________________________________…

6154. Resources | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/cauti-hospitals/toolkit-resources.html
      February 01, 2023 - Resources Toolkit for Reducing CAUTI in Hospitals The Resources module of the Toolkit for Reducing CAUTI in Hospitals links to additional resources for CAUTI prevention and safety culture improvement. Tools Preventing CAUTI in the ICU Setting This four-module narrated presentation is designed for inte…

6155. Value Stream Mapping | Digital Healthcare Research
      digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/value-stream-mapping
      January 01, 2023 - Value Stream Mapping Acronym VSM Description Value stream mapping (VSM) is a method of improvement that allows an entire process to be visualized. It represents the flow of both materials and information in an attempt to improve a process by finding sources of waste. The technique identifies a…

6156. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37543/psn-pdf
      March 03, 2011 - Rates of medication errors among depressed and burnt out residents: prospective cohort study. March 3, 2011 Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. 2008;336(7642):488-91. doi:10.1136/bmj.39469.763218.BE. https:/…

6157. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43604/psn-pdf
      October 15, 2014 - The challenges in monitoring and preventing patient safety incidents for people with intellectual disabilities in NHS acute hospitals: evidence from a mixed-methods study. October 15, 2014 Tuffrey-Wijne I, Goulding L, Gordon V, et al. The challenges in monitoring and preventing patient safety incidents for people…

6158. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39583/psn-pdf
      October 30, 2010 - The harm susceptibility model: a method to prioritise risks identified in patient safety reporting systems. October 30, 2010 Pham JC, Colantuoni E, Dominici F, et al. The harm susceptibility model: a method to prioritise risks identified in patient safety reporting systems. Qual Saf Health Care. 2010;19(5):440-5. …

6159. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43263/psn-pdf
      July 16, 2014 - Patient complaints in healthcare systems: a systematic review and coding taxonomy. July 16, 2014 Reader TW, Gillespie A, Roberts J. Patient complaints in healthcare systems: a systematic review and coding taxonomy. BMJ Qual Saf. 2014;23(8):678-689. doi:10.1136/bmjqs-2013-002437. https://psnet.ahrq.gov/issue/patien…

6160. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39213/psn-pdf
      October 03, 2017 - Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety. October 3, 2017 Szekendi MK, Barnard C, Creamer J, et al. Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety. Jt Comm J Qual Patient Saf. 2010;36(1):3-9. h…