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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/index.html
May 01, 2016 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention
The Agency for Healthcare Research and Quality (AHRQ) created On-Time Pressure Ulcer Prevention to help nursing homes with electronic medical records reduce the occurrence of in-house pressure ulcers. Pressure ulcers remain a serious pro…
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psnet.ahrq.gov/node/38877/psn-pdf
April 08, 2011 - Computerized order entry with limited decision support to
prevent prescription errors in a PICU.
April 8, 2011
Kadmon G, Bron-Harlev E, Nahum E, et al. Computerized order entry with limited decision support to
prevent prescription errors in a PICU. Pediatrics. 2009;124(3):935-940. doi:10.1542/peds.2008-2737.
https…
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psnet.ahrq.gov/node/39314/psn-pdf
December 21, 2014 - Patient characteristics and the occurrence of never
events.
December 21, 2014
Fry DE, Pine M, Jones BL, et al. Patient characteristics and the occurrence of never events. Arch Surg.
2010;145(2):148-51. doi:10.1001/archsurg.2009.277.
https://psnet.ahrq.gov/issue/patient-characteristics-and-occurrence-never-events
…
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psnet.ahrq.gov/node/865344/psn-pdf
March 27, 2024 - Use of computerized physician order entry with clinical
decision support to prevent dose errors in pediatric
medication orders: a systematic review.
March 27, 2024
Ruutiainen H, Holmström A-R, Kunnola E, et al. Use of computerized physician order entry with clinical
decision support to prevent dose errors in pedia…
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psnet.ahrq.gov/node/47225/psn-pdf
November 02, 2018 - Preventable adverse drug events among inpatients: a
systematic review.
November 2, 2018
Gates PJ, Meyerson SA, Baysari M, et al. Preventable Adverse Drug Events Among Inpatients: A
Systematic Review. Pediatrics. 2018;142(3):e20180805. doi:10.1542/peds.2018-0805.
https://psnet.ahrq.gov/issue/preventable-adverse-dru…
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psnet.ahrq.gov/node/43450/psn-pdf
May 06, 2015 - Advances in the Prevention and Control of HAIs.
May 6, 2015
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Rockville, MD: Agency for Healthcare Research and
Quality; June 2014. AHRQ Publication No. 14-0003.
https://psnet.ahrq.gov/issue/advances-prevention-and-control-hais
Health care–associated infections (HAI…
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psnet.ahrq.gov/node/34068/psn-pdf
July 10, 2008 - Pharmacists on rounding teams reduce preventable
adverse drug events in hospital general medicine units.
July 10, 2008
Kucukarslan SN, Peters M, Mlynarek M, et al. Pharmacists on rounding teams reduce preventable adverse
drug events in hospital general medicine units. Arch Intern Med. 2003;163(17):2014-8.
https://…
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www.ahrq.gov/pqmp/measures/dental-treatment-prevention.html
August 01, 2021 - Linkage Between Dental Treatment and Dental Prevention—PDENT-CH: Percentage of Eligibles Who Received Preventative Dental Services
Measure Domain: Management of Acute Conditions
Measure Sub-Domain: Dental Care
PQMP COE: PMCOE
Associated NQF # and Name: None
Products:
Fact Sheet: None
Full Report (…
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psnet.ahrq.gov/node/33600/psn-pdf
June 16, 2024 - Patient Safety 101
June 16, 2024
Patient Safety 101. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-safety-101
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in…
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www.ahrq.gov/nursing-home/learning-modules/covid-id-prevention.html
December 01, 2022 - COVID-19 Identification & Prevention series
This series of three learning modules focuses on identifying the signs and symptoms of COVID-19, knowing when and how to report signs and symptoms of COVID-19, and remembering to maintain infection prevention processes.
Module 1: COVID-19 Identification and Preventi…
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psnet.ahrq.gov/node/44525/psn-pdf
October 21, 2015 - Wound-care teams for preventing and treating pressure
ulcers.
October 21, 2015
Moore ZEH, Webster J, Samuriwo R. Wound-care teams for preventing and treating pressure ulcers.
Cochrane Database Syst Rev. 2015;9:CD011011. doi:10.1002/14651858.CD011011.pub2.
https://psnet.ahrq.gov/issue/wound-care-teams-preventing-an…
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psnet.ahrq.gov/node/37059/psn-pdf
September 30, 2011 - Preventable errors in the operating room--part 2: retained
foreign objects, sharps injuries, and wrong site surgery.
September 30, 2011
Dagi F, Berguer R, Moore S, et al. Preventable errors in the operating room--part 2: retained foreign
objects, sharps injuries, and wrong site surgery. Curr Probl Surg. 2007;44(6):…
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psnet.ahrq.gov/node/34033/psn-pdf
April 11, 2011 - Adverse events and preventable adverse events in
children.
April 11, 2011
Woods D, Thomas EJ, Holl JL, et al. Adverse events and preventable adverse events in children.
Pediatrics. 2005;115(1):155-60.
https://psnet.ahrq.gov/issue/adverse-events-and-preventable-adverse-events-children
Adverse events in hospitalize…
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psnet.ahrq.gov/node/41911/psn-pdf
December 12, 2012 - Effects of an intervention to increase bed alarm use to
prevent falls in hospitalized patients: a cluster
randomized trial.
December 12, 2012
Shorr RI, Chandler M, Mion LC, et al. Effects of an intervention to increase bed alarm use to prevent falls in
hospitalized patients: a cluster randomized trial. Ann Intern …
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psnet.ahrq.gov/node/50940/psn-pdf
February 26, 2020 - The effect of smartphone-based application learning on
the nursing students' performance in preventing
medication errors in the pediatric units.
February 26, 2020
Pourteimour S, Hemmati MalsakPak M, Jasemi M, et al. The effect of smartphone-based application
learning on the nursing students' performance in prevent…
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psnet.ahrq.gov/node/38950/psn-pdf
June 02, 2010 - Medication errors in chemotherapy: incidence, types and
involvement of patients in prevention. A review of the
literature.
June 2, 2010
Schwappach DLB, Wernli M. Medication errors in chemotherapy: incidence, types and involvement of
patients in prevention. A review of the literature. Eur J Cancer Care (Engl). 2010…
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psnet.ahrq.gov/node/857446/psn-pdf
December 06, 2023 - Community Health Systems’ ongoing journey to zero
preventable harm.
December 6, 2023
Simon LT, Van Buren T. Community Health Systems’ ongoing journey to zero preventable harm. NEJM
Catal Innov Care Deliv. 2023;4(12). doi:10.1056/cat.23.0250.
https://psnet.ahrq.gov/issue/community-health-systems-ongoing-journey-zer…
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psnet.ahrq.gov/node/46524/psn-pdf
October 18, 2017 - Pressure Injury Prevention in Hospitals Training Program.
October 18, 2017
Rockville, MD: Agency for Healthcare Research and Quality; September 2017.
https://psnet.ahrq.gov/issue/pressure-injury-prevention-hospitals-training-program
Pressure ulcers are a common hospital-acquired condition that can lead to patient h…
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www.ahrq.gov/patient-safety/settings/hospital/resource/about.html
December 01, 2017 - Hospital Resources
Toolkits, recommendations, and other resources for hospitals and hospital administrators to improve quality, reduce errors, and increase patient safety.
Sign up: CAHPS Database - Hospital Component Email updates
Sign up: Hospital Survey on Patient Safety Culture Email updates
Sign u…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/096-ss-glycemic-control-one-pager.docx
April 01, 2025 - Glycemic Control
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
Why is glycemic control important?1,2
Surgical patients, even without diabetes, are at risk for hyperglycemia
Hyperglycemia is associated with increased risk for surgical site infections (SSIs), mortality, and h…