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5201. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality | PSNet
      psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
      October 01, 2004 - For example, patient safety indicators derived from administrative data sources can be valuable tools … First, the current immunization measures apply only to patients with pneumonia, so while this patient … Safety of intramuscular influenza immunization among patients receiving long-term warfarin anticoagulation … May 27, 2011 Improving nurse-to-patient staffing ratios as a cost-effective safety intervention … Health Plan Patient Safety Initiatives July 10, 2024

5202. Aseptic Catheter Insertion Practices in the ED: A Focus on Engagement | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/aseptic-catheter-insertion-practices-ed-slides.html
      December 01, 2017 - Slide 8 Lack of Feedback & Strategy to Overcome Patients move from the ED to other units, and … there is no systematic process to let ED staff know of patient outcomes. … supplies: Over-the-bed tables Hand sanitizers Sterile gloves Best type of kit to stock for your patient … Transition to an evidence-based practice approach for patient care delivery: Several evidence-based … Healthcare Research and Quality through the contract, “National Implementation of Comprehensive Unit-based Safety

5203. Statewide identification of adverse events using retrospective nurse review: methods and outcomes. | PSNet
      psnet.ahrq.gov/issue/statewide-identification-adverse-events-using-retrospective-nurse-review-methods-and-outcomes
      November 21, 2021 - November 21, 2021 Indication-specific opioid prescribing for US patients with Medicaid … July 16, 2018 Do patients' disruptive behaviours influence the accuracy of a doctor's … September 27, 2016 Do clinicians know which of their patients have central venous catheters … September 12, 2012 Registered nurses' judgments of the classification and risk level of patient … View More See More About The Topic Nurses Nurse Managers Quality and Safety

5204. A Model-based Approach to Prioritizing Medical Safety Practices (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Marken.pdf
      January 01, 2004 - safety issues, as called for by the IOM and more recent findings recognizing threats to patient safety … area, the policies being evaluated are medical safety practices aimed at reducing harm to patients … Advances in Patient Safety: Vol. 2 414 Table 1. … Making health care safer: a critical analysis of patient safety practices. … What practices will most improve safety? Evidence-based medicine meets patient safety.

5205. Urinary Tract Infections (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/uti-one-pager.pdf
      September 01, 2022 - o Sending a urine culture in the absence of symptoms is indicated only early during pregnancy or in patients … urinary catheterization  Pyelonephritis or ill appearance o Urine culture should not be sent if the patient … cloudy urine or for a positive urine dipstick in the absence of other symptoms1 • Third, give the patient … with cystitis should seek further medical care if symptoms are not improving by day 3 or if patients … more ill at any time AHRQ Safety Program for Improving Antibiotic Use – Ambulatory

5206. Care Coordination | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/carecoordination.html
      June 01, 2018 - Patient Safety, Person-Centered Care, and Healthy Living measures have improved overall, but many disparities … Improve the quality of life for patients with chronic illness and disability by following a current care … to create a delivery system that is less fragmented and more organized, where handoffs are clear and patients … and clinicians have the information they need to optimize the patient-clinician partnership (NQS, 2011 … receives appropriate care and support, when and how the patient needs and wants it.

5207. Improving-Facnotes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving-facnotes.docx
      May 01, 2017 - Furthermore, lack of communication has resulted in serious patient safety events such as teams performing … One example used by many facilities is the AHRQ Survey on Patient Safety culture. … Through these measures, briefings can help improve patient safety. … They can help promote patient safety by reinforcing the importance of discussions that might improve … We want to minimize the risk to the patient as much as possible, but teams can miss critical safety steps

5208. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33570/psn-pdf
      June 15, 2024 - Background The past decade's quest to improve patient safety has chiefly addressed quantifiable problems … Diagnostic error has received comparatively less attention, despite the fact that landmark patient safety … /psnet.ahrq.gov/issue/using-medical-malpractice-closed-claims-data-reduce-surgical-risk-and-improve-patient-safety … https://psnet.ahrq.gov/issue/improving-diagnosis-health-care https://psnet.ahrq.gov/primer/reporting-patient-safety-events … https://psnet.ahrq.gov/primer/culture-safety https://psnet.ahrq.gov/primer/measurement-patient-safety

5209. Gap Analysis for MRSA Prevention (Unit-Level) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/122-unit-level-gap-analysis.pdf
      June 02, 2025 - Prevention (Unit-Level) AHRQ Safety … ]  Yes  No AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU | 2 GAP Analysis (Unit-Level … hygiene  Aseptic technique  Maximal sterile barrier precautions (e.g., full body drape for the patient … AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU | 9 GAP Analysis (Unit-Level) … hygiene: Off Aseptic technique: Off Maximal sterile barrier precautions eg full body drape for the patient

5210. Appendix C: List of Web Sites Reviewed | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamilyapc.html
      July 01, 2018 - Safety Institute Consumers Advancing Patient Safety Case Manager Society of America Center for Advancing … Induced Trauma Support Services Medicare Rights Center Minnesota Alliance for Patient Safety NASHP … Safety Agency (United Kingdom) National Patient Safety Foundation National Transitions in Care Coalition … Safety Patient/Family Safety Council—Calgary, Alberta Patients are Powerful Patients.About.Com Persons … Winnepeg Patient Safety Council World Health Organization—Patients for Patient Safety Return to

5211. Final Progress Report: Diagnostic Error in Medicine Annual Conference (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/trowbridge-report.pdf
      January 01, 2025 - It created significant impact in the fields of clinical medicine, cognitive psychology, patient safety … Key Words: diagnostic error, patient engagement, patient safety 1R13HS024883-01 (R. … Neither this report, nor the subsequent AHRQ review of useful patient safety practices, “A Critical … Analysis of Patient Safety Practices,” however, meaningfully addressed the concept of diagnostic error … Making health care safer: a critical analysis of patient safety practices.

5212. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74022/psn-pdf
      March 01, 2021 - The Role of Community Pharmacists in Patient Safety October 25, 2021 Luchen GG, Hall KK, Hough KR. … The Role of Community Pharmacists in Patient Safety . PSNet [internet]. 2021. … https://psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety What is a community pharmacy … Patient safety is best achieved in organizations that have a strong culture of safety. … Organizations with a strong culture of safety are not only better positioned to ensure patient safety

5213. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841566/psn-pdf
      December 14, 2022 - safety indicators that are used by CMS. … our efforts on patient safety to create deep systems of patient safety. … Workforce safety is part of patient safety. … We believe it is important that patients have a role in patient safety, including sitting on governance … voice and engaging patients in quality and safety measurement.

5214. Decisionmaker Brief: Computerized Provider Order Entry (CPOE) | Digital Healthcare Research
      digital.ahrq.gov/decisionmaker-brief-computerized-provider-order-entry-cpoe
      January 01, 2023 - Computerized provider order entry (CPOE) holds promise to improve the safety and efficiency of medication … In contrast, verbal and written order entry processes, without systematic integration of patients' medical … information, may result in order entry errors that pose a serious threat to patient safety and reduce … Wisconsin), including several projects in low-income and rural areas and areas with high percentages of patients … safety and reducing health care costs.

5215. Enhancing Quality in Patient Care (EQUIP) Project - 2009 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/enhancing-quality-patient-care-equip-project/annual-summary/2009
      January 01, 2009 - ) Utilize the EHR/data warehouse to facilitate continuous improvement of health care quality and safety … the full potential of EHR use in ambulatory care settings, particularly among safety net providers, … to improve health care quality and safety. ( Achieved ) Impact and Findings: The EHR implementation … These include: a) utilization of the chronic care model to manage disease and populations of patients … readiness, which aided in the smooth and rapid transition for point-of-care staff who continued to see patients

5216. 50-Multimodal-Analgesia-Facilitator (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/50-multimodal-analgesia-facilitator.docx
      June 01, 2023 - Multimodal Analgesia Tips: Facilitator Guide AHRQ Safety Program for Improving Surgical Care and Recovery … you adopt multimodal analgesia concepts from the Agency for Healthcare Research and Quality, AHRQ, Safety … goal to minimize overall opioid use and therefore decrease opiate related side effects and facilitate patient … This slide shows the relative potencies, expressed as NNT or the number of patients needed to treat to … control than single-agent alternatives while minimizing opiate-related side effects and facilitating patient

5217. Statistical Brief #114
      hcup-us.ahrq.gov/reports/statbriefs/sb114.jsp
      May 01, 2011 - Variables for Revisit Analyses American Hospital Association (AHA) Linkage Files AHRQ Quality Indicators … In January 2011, Congress reintroduced legislation to set minimum safety standards for concussion management … Sports related concussions by patient age The ED visits for sports related concussion are highly … Patient discharge status for sports related concussions Figure 2 shows that the vast majority (95.4 … Level of loss of consciousness by patient discharge status for sports related concussions, 2008.

5218. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures | PSNet
      psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
      November 27, 2019 - There was no mention of abdominal wall varices, but this is a common pitfall in operating on patients … CPR often needs to be paused in the setting of acute ATLS procedures in order to ensure safety. … June 19, 2024 Frontline providers' and patients' perspectives on improving diagnostic … safety in the emergency department: a qualitative study. … July 12, 2023 The Psychological Safety Scale of the Safety, Communication, Operational

5219. Improving Communication and Teamwork in the Surgical Environment
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-p.pptx
      January 01, 2015 - Evaluating and Selecting Hand Hygiene Products AHRQ Safety Program for Ambulatory Surgery Implementation … State University College of Nursing Evaluating and Selecting Hand Hygiene Products | ‹#› AHRQ Safety … specific clinical setting Objectives Evaluating and Selecting Hand Hygiene Products | ‹#› AHRQ Safety … Ambulatory Surgery Implementation Guide Appendix P Hand hygiene Effective strategies Personnel Patients … characteristics External environment Understanding Hand Hygiene Product Evaluation Safety

5220. In Conversation With... Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO | PSNet
      psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
      January 12, 2022 - Safety Organizations (PSOs) are organizations dedicated to improving patient safety and healthcare quality … safety risks in both COVID-19 and non-COVID-19 patients. … Many aspects of patient safety had to be adapted. … Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic January … data voluntarily submitted by federally listed Patient Safety Organizations (PSOs) to the Patient Safety