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9221. Appendix M. Example of a Nurse-Driven Protocol for Catheter Removal | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/impl-guide/implementation-guide-appendix-m.html
      October 01, 2020 - Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide Appendix M. Example of a Nurse-Driven Protocol for Catheter Removal Previous Page Next Page Table of Contents Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units…

9222. The patient who falls: "It's always a trade-off." | PSNet
      psnet.ahrq.gov/issue/patient-who-falls-its-always-trade
      February 17, 2011 - Commentary The patient who falls: "It's always a trade-off." Citation Text: Tinetti ME, Kumar C. The patient who falls: "It's always a trade-off". JAMA. 2010;303(3):258-66. doi:10.1001/jama.2009.2024. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML E…

9223. Newman Memorial Hospital Implements AHRQ's Patient Safety Culture Survey | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsroom/case-studies/cquips1301.html
      November 01, 2012 - Newman Memorial Hospital Implements AHRQ's Patient Safety Culture Survey Search All Impact Case Studies November 2012 Newman Memorial Hospital, a 79-bed acute hospital in Oklahoma, first implemented AHRQ's "Hospital Survey on Patient Safety Culture" in 2006, when concern about the hospital's patient safety …

9224. Characteristics associated with postdischarge medication errors. | PSNet
      psnet.ahrq.gov/issue/characteristics-associated-postdischarge-medication-errors
      April 12, 2023 - Study Characteristics associated with postdischarge medication errors. Citation Text: Mixon A, Myers AP, Leak CL, et al. Characteristics associated with postdischarge medication errors. Mayo Clin Proc. 2014;89(8):1042-51. doi:10.1016/j.mayocp.2014.04.023. Copy Citation Format: …

9225. The Physician Practice Patient Safety Assessment. | PSNet
      psnet.ahrq.gov/issue/physician-practice-patient-safety-assessment
      April 24, 2018 - Measurement Tool/Indicator The Physician Practice Patient Safety Assessment. Citation Text: Pohl JM, Nath R, Zheng K, et al. Use of a comprehensive patient safety tool in primary care practices. Journal of the American Association of Nurse Practitioners. 2013;25(8):415-8. doi:10.1111/174…

9226. Unintentionally retained guidewires: a descriptive study of 73 sentinel events. | PSNet
      psnet.ahrq.gov/issue/unintentionally-retained-guidewires-descriptive-study-73-sentinel-events
      April 27, 2019 - Study Unintentionally retained guidewires: a descriptive study of 73 sentinel events. Citation Text: Steelman VM, Thenuwara K, Shaw C, et al. Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events. Jt Comm J Qual Saf. 2019;45(2):81-90. doi:10.1016/j.jcjq.2018.08.0…

9227. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. | PSNet
      psnet.ahrq.gov/issue/designing-safer-process-prevent-retained-surgical-sponges-healthcare-failure-mode-and-effect
      April 27, 2019 - Study Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. Citation Text: Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. AORN J. 2011;94(2):1…

9228. Serious hazards of transfusion (SHOT) haemovigilance and progress is improving transfusion safety. | PSNet
      psnet.ahrq.gov/issue/serious-hazards-transfusion-shot-haemovigilance-and-progress-improving-transfusion-safety
      April 27, 2019 - Review Serious hazards of transfusion (SHOT) haemovigilance and progress is improving transfusion safety. Citation Text: Bolton-Maggs PHB, Cohen H. Serious Hazards of Transfusion (SHOT) haemovigilance and progress is improving transfusion safety. Br J Haematol. 2013;163(3):303-14. doi…

9229. Subcommittee on Quality Measures for Children's Healthcare for Medicaid and CHIP | Agency for Healthcare Research and Quality
      www.ahrq.gov/policymakers/chipra/snac_members.html
      November 01, 2013 - Subcommittee on Quality Measures for Children's Healthcare for Medicaid and CHIP Members List: 2013 List of 2013 members of the Subcommittee on Quality Measures for Children's Healthcare (SNAC). Mary S. Applegate, MD, FAAP, FACP Medicaid Medical Director for Ohio Office of Medical Assistance Columbus, OH…

9230. Foreword | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/tools/confid-report/foreword.html
      February 01, 2016 - Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance Foreword Previous Page Next Page Table of Contents Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance Foreword Introduction Part One: Physician Feedback Report Fundamentals …

9231. Shifting the learning curve. | PSNet
      psnet.ahrq.gov/issue/shifting-learning-curve
      March 09, 2009 - Commentary Shifting the learning curve. Citation Text: Reynolds T, Kong M-L. Shifting the learning curve. BMJ. 2010;341:c6260. doi:10.1136/bmj.c6260. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

9232. Electronic prescribing in pediatrics: toward safer and more effective medication management. | PSNet
      psnet.ahrq.gov/issue/electronic-prescribing-pediatrics-toward-safer-and-more-effective-medication-management
      October 04, 2011 - Organizational Policy/Guidelines Electronic prescribing in pediatrics: toward safer and more effective medication management. Citation Text: Committee 2011–2012 AA of PC on CITE. Electronic prescribing in pediatrics: toward safer and more effective medication management. Pediatrics. 2…

9233. Patient-assisted incident reporting: including the patient in patient safety. | PSNet
      psnet.ahrq.gov/issue/patient-assisted-incident-reporting-including-patient-patient-safety
      June 16, 2011 - Commentary Patient-assisted incident reporting: including the patient in patient safety. Citation Text: Millman A, Pronovost P, Makary MA, et al. Patient-assisted incident reporting: including the patient in patient safety. J Patient Saf. 2011;7(2):106-8. doi:10.1097/PTS.0b013e31821b3c…

9234. Care transitions in the outpatient surgery preoperative process: facilitators and obstacles to information flow and their consequences. | PSNet
      psnet.ahrq.gov/issue/care-transitions-outpatient-surgery-preoperative-process-facilitators-and-obstacles
      December 31, 2014 - Study Care transitions in the outpatient surgery preoperative process: facilitators and obstacles to information flow and their consequences. Citation Text: Schultz K, Carayon P, Hundt AS, et al. Care transitions in the outpatient surgery preoperative process: facilitators and obstacl…

9235. Improving RCA performance: the Cornerstone Award and the power of positive reinforcement. | PSNet
      psnet.ahrq.gov/issue/improving-rca-performance-cornerstone-award-and-power-positive-reinforcement
      September 03, 2015 - Study Improving RCA performance: the Cornerstone Award and the power of positive reinforcement. Citation Text: Bagian JP, King BJ, Mills PD, et al. Improving RCA performance: the Cornerstone Award and the power of positive reinforcement. BMJ Qual Saf. 2011;20(11):974-82. doi:10.1136/bm…

9236. The perianesthesia nurse's role in the prevention of opioid-related sentinel events. | PSNet
      psnet.ahrq.gov/issue/perianesthesia-nurses-role-prevention-opioid-related-sentinel-events
      November 25, 2020 - Commentary The perianesthesia nurse's role in the prevention of opioid-related sentinel events. Citation Text: Pasero C. The perianesthesia nurse's role in the prevention of opioid-related sentinel events. J Perianesth Nurs. 2013;28(1):31-7. doi:10.1016/j.jopan.2012.11.001. Copy Citat…

9237. The medication kit conundrum: considerations to enhance safety and efficiency. | PSNet
      psnet.ahrq.gov/issue/medication-kit-conundrum-considerations-enhance-safety-and-efficiency
      June 07, 2017 - Commentary The medication kit conundrum: considerations to enhance safety and efficiency. Citation Text: Arthur KJ, Fuller J, Dossett HA, et al. The medication kit conundrum: considerations to enhance safety and efficiency. Am J Health Syst Pharm. 2024;Epub Sep 4. doi:10.1093/ajhp/zxae23…

9238. Doctors' thinking about 'the system' as a threat to patient safety. | PSNet
      psnet.ahrq.gov/issue/doctors-thinking-about-system-threat-patient-safety
      December 09, 2020 - Study Doctors' thinking about 'the system' as a threat to patient safety. Citation Text: Waring J. Doctors' thinking about 'the system' as a threat to patient safety. Health (London). 2007;11(1):29-46. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndN…

9239. Targeted communication intervention using nursing crew resource management principles. | PSNet
      psnet.ahrq.gov/issue/targeted-communication-intervention-using-nursing-crew-resource-management-principles
      August 12, 2015 - Study Targeted communication intervention using nursing crew resource management principles. Citation Text: Tschannen D, McClish D, Aebersold M, et al. Targeted communication intervention using nursing crew resource management principles. J Nurs Care Qual. 2015;30(1):7-11. doi:10.1097/NC…

9240. Infusing fun into quality and safety initiatives. | PSNet
      psnet.ahrq.gov/issue/infusing-fun-quality-and-safety-initiatives
      October 19, 2022 - Commentary Infusing fun into quality and safety initiatives. Citation Text: Foulk KC, Tocydlowski P, Snow TM, et al. Infusing fun into quality and safety initiatives. Nursing (Brux). 2012;42(11):14-16. doi:10.1097/01.NURSE.0000421386.36112.a9. Copy Citation Format: DOI Goo…