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Comparing rates of adverse events and medical errors on inpatient psychiatric units at Veterans Health Administration and community-based general hospitals. | PSNet

psnet.ahrq.gov/issue/comparing-rates-adverse-events-and-medical-errors-inpatient-psychiatric-units-veterans-health

January 30, 2019 - Study Comparing rates of adverse events and medical errors on inpatient psychiatric units at Veterans Health Administration and community-based general hospitals. Citation Text: Cullen SW, Xie M, Vermeulen JM, et al. Comparing Rates of Adverse Events and Medical Errors on Inpatient Psych…
CANDOR Event Checklist | Agency for Healthcare Research and Quality

www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist4.html

August 01, 2022 - CANDOR Event Checklist AHRQ Communication and Optimal Resolution Toolkit Purpose: To provide a checklist for the required actions that need to be taken following an event. Who should use this tool? The Communication and Optimal Resolution (CANDOR) Response Team or designee, unless otherwise indicated. …
Mod4-Event-Checklist (pdf file)

www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-event-checklist.pdf

April 01, 2016 - Purpose: To provide a checklist for the required actions that need to be taken following an event. Who should use this tool? The Communication and Optimal Resolution Toolkit (CANDOR) Response Team or designee, unless otherwise indicated. How to use this tool: Use the checklist to ensure that appropriate action is t…
Improving the governance of patient safety in emergency care: a systematic review of interventions. | PSNet

psnet.ahrq.gov/issue/improving-governance-patient-safety-emergency-care-systematic-review-interventions

March 06, 2013 - Review Improving the governance of patient safety in emergency care: a systematic review of interventions. Citation Text: Hesselink G, Berben S, Beune T, et al. Improving the governance of patient safety in emergency care: a systematic review of interventions. BMJ Open. 2016;6(1):e009837…
Methods | Agency for Healthcare Research and Quality

www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-test-result-communication3.html

July 01, 2024 - Electronic Test Result Communication in the Era of the 21st Century Cures Act Methods Previous Page Next Page Table of Contents Electronic Test Result Communication in the Era of the 21st Century Cures Act Introduction Methods Results Discussion Conclusions References Appendix A. Datab…
The Theory of Distributed Cognition | Agency for Healthcare Research and Quality

www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses2.html

August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department The Theory of Distributed Cognition Previous Page Next Page Table of Contents Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Introduction The Theory of Dis…
ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2013. | PSNet

psnet.ahrq.gov/issue/ashp-national-survey-pharmacy-practice-hospital-settings-prescribing-and-transcribing-2013

September 30, 2020 - Study ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2013. Citation Text: Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Prescribing and transcribing-2013. Am J Health Syst Pharm. 2…
Exploring the human factors of prescribing errors in paediatric intensive care units. | PSNet

psnet.ahrq.gov/issue/exploring-human-factors-prescribing-errors-paediatric-intensive-care-units

March 06, 2024 - Study Emerging Classic Exploring the human factors of prescribing errors in paediatric intensive care units. Citation Text: Sutherland A, Ashcroft DM, Phipps D. Exploring the human factors of prescribing errors in paediatric intensive care units. Arch Dis Child.…
Retained guidewires in the Veterans Health Administration: getting to the root of the problem. | PSNet

psnet.ahrq.gov/issue/retained-guidewires-veterans-health-administration-getting-root-problem

March 13, 2013 - Study Retained guidewires in the Veterans Health Administration: getting to the root of the problem. Citation Text: Cherara L, Sculli GL, Paull DE, et al. Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem. J Patient Saf. 2021;17(8):e991-e928. d…
Case Studies | Agency for Healthcare Research and Quality

www.ahrq.gov/hai/cusp/clabsi-hpwpreport/clabsi-hpwp2.html

August 01, 2015 - High-Performance Work Practices in CLABSI Prevention Interventions Case Studies Previous Page Next Page Table of Contents High-Performance Work Practices in CLABSI Prevention Interventions Case Studies Key Findings Conclusions References Table 1. Case Study Sites Table 2. Summary of Ke…
Abstract | Agency for Healthcare Research and Quality

www.ahrq.gov/policymakers/chipra/measure_retirement/measure_retirement1.html

February 01, 2014 - Background Report on 2013 Retirement of Measures from the Child Core Set Abstract Previous Page Next Page Table of Contents Background Report on 2013 Retirement of Measures from the Child Core Set Abstract Background Methods Results Conclusions References Appendix A. Appendix B. …
Blood and blood products transfusion errors: what can we do to improve patient safety. | PSNet

psnet.ahrq.gov/issue/blood-and-blood-products-transfusion-errors-what-can-we-do-improve-patient-safety

September 23, 2020 - Review Blood and blood products transfusion errors: what can we do to improve patient safety. Citation Text: Brown C, Brown M. Blood and blood products transfusion errors: what can we do to improve patient safety? Br J Nurs. 2023;32(7):326-332. doi:10.12968/bjon.2023.32.7.326. Copy Cit…
Preventing Infections in Endoscopic Procedures (pdf file)

www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-m.pdf

May 01, 2017 - Preventing Infections in Endoscopic Procedures Appendix M. Endoscopy Infographic AHRQ Safety Program for Ambulatory Surgery Implementation Guide Empower patients and families to insist that all team members wash their hands before providing care; encourage patients and families to perform hand hygie…
The accuracy of medical dispatch—a systematic review. | PSNet

psnet.ahrq.gov/issue/accuracy-medical-dispatch-systematic-review

March 12, 2025 - Review The accuracy of medical dispatch—a systematic review. Citation Text: Bohm K, Kurland L. The accuracy of medical dispatch - a systematic review. Scand J Trauma Resusc Emerg Med. 2018;26(1):94. doi:10.1186/s13049-018-0528-8. Copy Citation Format: DOI Google Scholar Pub…
Module 3: PowerPoint Presentation

www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/problem-solving/problem-solving.pptx

May 01, 2017 - Module 3: PowerPoint Presentation Management Practices for Sustainability Module 3: Problem Solving and Escalation AHRQ Safety Program for Ambulatory Surgery AHRQ Pub. No. 16(17)-0019-4-EF May 2017 Module 3: Problem Solving and Escalation | ‹#› AHRQ Safety Program for Ambulatory Surgery Management Practices for…
Speaking the same language? International variations in the safety information accompanying top-selling prescription drugs. | PSNet

psnet.ahrq.gov/issue/speaking-same-language-international-variations-safety-information-accompanying-top-selling

September 25, 2008 - Study Speaking the same language? International variations in the safety information accompanying top-selling prescription drugs. Citation Text: Kesselheim AS, Franklin JM, Avorn J, et al. Speaking the same language? International variations in the safety information accompanying top-se…
Sharing lessons learned to prevent adverse events in anesthesiology nationwide. | PSNet

psnet.ahrq.gov/issue/sharing-lessons-learned-prevent-adverse-events-anesthesiology-nationwide

April 12, 2019 - Study Sharing lessons learned to prevent adverse events in anesthesiology nationwide. Citation Text: Soncrant C, Neily J, Sum-Ping SJT, et al. Sharing Lessons Learned to Prevent Adverse Events in Anesthesiology Nationwide. J Patient Saf. 2021;17(4):e343-e349. doi:10.1097/PTS.000000000000…
Patient safety goals for the proposed Federal Health Information Technology Safety Center. | PSNet

psnet.ahrq.gov/issue/patient-safety-goals-proposed-federal-health-information-technology-safety-center

November 30, 2011 - Commentary Classic Patient safety goals for the proposed Federal Health Information Technology Safety Center. Citation Text: Sittig DF, Classen D, Singh H. Patient safety goals for the proposed Federal Health Information Technology Safety Center. J Am Med Inform…
U.S. Preventive Services Task Force Issues Final Recommendation on Screening for Syphilis Infection (pdf file)

www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/syphilis-nonpregnant-adults-adolescents-screening-final-rec-bulletin.pdf

September 27, 2022 - U.S. Preventive Services Task Force Issues Final Recommendation on Screening for Syphilis Infection http://www.uspreventiveservicestaskforce.org 1 U.S. Preventive Services Task Force Issues Final Recommendation on Screening for Syphilis Infection Task Force recommends screening people at increased risk fo…
How To Choose a PSO | PSO

pso.ahrq.gov/work-with/choose

November 01, 2020 - SHARE: More topics in this section Work With a PSO How To Choose a PSO Become a PSO Maintain a PSO Listing How To Choose a PSO Are you eligible to work with a PSO? An individual or entity licensed or ot…