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www.ahrq.gov/hai/cauti-tools/guides/implguide-pt2.html
October 01, 2015 - Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Frameworks for Change and Improvement
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Table of Contents
Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Overvi…
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psnet.ahrq.gov/node/72581/psn-pdf
December 16, 2020 - Dispensing Errors.
December 16, 2020
Phipps D, Ashour A, Riste L, et al. The Pharmaceutical Journal. 2020;305(7943, 7944).
November 10, December 1, 2020.
https://psnet.ahrq.gov/issue/dispensing-errors
Dispensing mistakes are a common contributor to preventable adverse events in community pharmacies.
Par…
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psnet.ahrq.gov/node/34681/psn-pdf
February 09, 2011 - No-fault compensation for medical injuries: the prospect
for error prevention.
February 9, 2011
Studdert DM, Brennan TA. No-Fault Compensation for Medical Injuries. JAMA. 2003;286(2).
doi:10.1001/jama.286.2.217.
https://psnet.ahrq.gov/issue/no-fault-compensation-medical-injuries-prospect-error-prevention
The auth…
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psnet.ahrq.gov/node/45885/psn-pdf
May 03, 2017 - E-collection: Safety and Error Prevention in Health.
May 3, 2017
https://psnet.ahrq.gov/issue/e-collection-safety-and-error-prevention-health
The increasing implementation of health information technology has introduced both benefits and
challenges to patient safety. Articles in this series explore the impacts of t…
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psnet.ahrq.gov/node/865493/psn-pdf
April 03, 2024 - Implement strategies to prevent persistent medication
errors and hazards: 2024.
April 3, 2024
ISMP Medication Safety Alert! Acute Care. 2024;29(6):1-4.
https://psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards-2024
Systemic failures can perpetuate unsafe care if a lack of p…
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psnet.ahrq.gov/node/837339/psn-pdf
June 08, 2022 - Mindful workarounds in bar code medication
administration.
June 8, 2022
Lichtner V, Dowding D. Mindful workarounds in bar code medication administration. Stud Health Technol
Inform. 2022;294:740-744. doi:10.3233/shti220575.
https://psnet.ahrq.gov/issue/mindful-workarounds-bar-code-medication-administration
Barcod…
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psnet.ahrq.gov/node/44488/psn-pdf
September 16, 2015 - Environmental Cleaning for the Prevention of Healthcare-
Associated Infections (HAIs).
September 16, 2015
Leas BF, Sullivan N, Han JH, Pegues DA, Kaczmarek JL, Umscheid CA. Rockville, MD: Agency for
Healthcare Research and Quality; August 2015. Technical Brief No. 22. AHRQ Publication No. 15-
EHC020-EF.
https://p…
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psnet.ahrq.gov/node/73619/psn-pdf
August 18, 2021 - Use systems redesign and the law to prevent medical
errors and accidents.
August 18, 2021
Saks MJ, Landsman S. STAT. August 4, 2021.
https://psnet.ahrq.gov/issue/use-systems-redesign-and-law-prevent-medical-errors-and-accidents
This article introduces the systemic task of medical error reduction and discusses the …
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psnet.ahrq.gov/node/44983/psn-pdf
April 20, 2016 - Back to basics: counting soft surgical goods.
April 20, 2016
Spruce L. Back to Basics: Counting Soft Surgical Goods. AORN J. 2016;103(3):298-301; quiz 302-3.
doi:10.1016/j.aorn.2015.12.021.
https://psnet.ahrq.gov/issue/back-basics-counting-soft-surgical-goods
Despite heightened awareness of hazards associated with…
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psnet.ahrq.gov/node/50838/psn-pdf
January 29, 2020 - Start the new year off right by preventing these top 10
medication errors and hazards.
January 29, 2020
ISMP Medication Safety Alert! Acute care edition. January 16, 2020;26(2):1-6.
https://psnet.ahrq.gov/issue/start-new-year-right-preventing-these-top-10-medication-errors-and-hazards
Medication errors routinely c…
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digital.ahrq.gov/ahrq-funded-projects/user-centered-designed-anticoagulation-shared-decision-making-tool-stroke/citation/web
January 01, 2025 - A web-based tool to perform a values clarification for stroke prevention in patients with atrial fibrillation: Design and preliminary testing study.
Citation
Dorsch MP, Flynn AJ, Greer KM, Ganai S, Barnes GD, Zikmund-Fisher B. A web-based tool to perform a values clarification for stroke prevention in…
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digital.ahrq.gov/ahrq-funded-projects/preventing-wrong-drug-and-wrong-patient-errors-indication-alerts-cpoe-systems/final-report
January 01, 2023 - Preventing Wrong-Drug and Wrong-Patient Errors With Indication Alerts in CPOE Systems - Final Report
Citation
Lambert B. Preventing Wrong-Drug and Wrong-Patient Errors With Indication Alerts in CPOE Systems – Final Report. (Prepared by Northwestern University under Grant No. R01 HS024945). Rockville, …
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digital.ahrq.gov/ahrq-funded-projects/use-patient-buddy-application-disseminate-knowledge-prevent-readmission/final-report
January 01, 2023 - Use of Patient Buddy™ Application to Disseminate Knowledge & Prevent Readmission - Final Report
Citation
Bajaj, J. Use of Patient Buddy™ Application to Disseminate Knowledge & Prevent Readmission - Final Report. (Prepared by Virginia Commonwealth University under Grant No. R21 HS024004). Rockville, MD…
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digital.ahrq.gov/ahrq-funded-projects/health-information-technology-supported-process-preventing-and-managing-venous-thromboembolism/final-report
January 01, 2023 - Health Information Technology-Supported Process for Preventing and Managing Venous Thromboembolism - Final Report
Citation
Carayon P. Health Information Technology-Supported Process for Preventing and Managing Venous Thromboembolism - Final Report. (Prepared by the University of Wisconsin - Madison un…
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digital.ahrq.gov/ahrq-funded-projects/prevent-diabetes-mellitus-predm-clinical-decision-support-intervention/citation/development
January 01, 2023 - Development of a novel clinical decision support tool for diabetes prevention and feasibility of its implementation in primary care.
Citation
O'Brien MJ, Vargas MC, Lopez A, Feliciano Y, Gregory DL, Carcamo P, Mohr L, Mohanty N, Padilla R, Ackermann RT, Persell SD, Feinglass J. Development of a novel …
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digital.ahrq.gov/ahrq-funded-projects/sharing-patient-lifelog-data-primary-care-team-two-patient-populations/final-report
January 01, 2023 - Sharing Patient Lifelog Data With the Primary Care Team for Two Patient Populations: Preventative Care & Chronic Disease Management - Final Report.
Citation
Munson S. Sharing Patient Lifelog Data With the Primary Care Team for Two Patient Populations: Preventative Care & Chronic Disease Management - F…
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psnet.ahrq.gov/node/847057/psn-pdf
April 05, 2023 - Implement strategies to prevent persistent medication
errors and hazards.
April 5, 2023
ISMP Medication Safety Alert! Acute care edition. March 23, 2023;28(6):1-4.
https://psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards
Medication mistakes are recognized contributors to p…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-harms.pdf
August 01, 2025 - AHRQ-Funded Patient Safety Project Highlights
AHRQ-Funded Patient Safety
Project Highlights
Improving Healthcare Safety by Preventing
Procedural Harms and In-Facility Injuries
In the delivery of healthcare, practices are implemented that prevent procedural harms and in-facility
injuries to improve the safety of …
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-resource-list.pdf
April 01, 2023 - Resource List - AHRQ Ambulatory Surgery Center Survey
SOPS Ambulatory Surgery Center Survey Resource List 1
Improving Patient Safety in Ambulatory Surgery
Centers: A Resource List for Users of the AHRQ
Ambulatory Surgery Center Survey on Patient Safety
Culture
I. Purpose
This document provides a list of ref…
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psnet.ahrq.gov/issue/joint-commission-perspectives-patient-safety
February 28, 2018 - Newsletter/Journal
Joint Commission Perspectives on Patient Safety.
Citation Text:
Joint Commission Perspectives on Patient Safety. Joint Commission Resources
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