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psnet.ahrq.gov/node/60801/psn-pdf
August 12, 2020 - Targeting zero harm: a stretch goal that risks breaking the
spring.
August 12, 2020
Meddings J, Saint S, Lilford RJ, et al. Targeting zero harm: a stretch goal that risks breaking the spring.
NEJM Catal Innov Care Deliv. 2020;1(4). doi:10.1056/cat.20.0354.
https://psnet.ahrq.gov/issue/targeting-zero-harm-stretch-g…
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psnet.ahrq.gov/node/41398/psn-pdf
May 30, 2012 - How should medication errors be defined? Development
and test of a definition.
May 30, 2012
Lisby M, Nielsen LP, Brock B, et al. How should medication errors be defined? Development and test of a
definition. Scand J Public Health. 2012;40(2):203-10. doi:10.1177/1403494811435489.
https://psnet.ahrq.gov/issue/how-sh…
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psnet.ahrq.gov/node/46881/psn-pdf
March 28, 2018 - Designing for Safety in the ICU.
March 28, 2018
Hamilton DK, ed. Crit Care Nurs Q. 2018;41(1):1-92.
https://psnet.ahrq.gov/issue/designing-safety-icu
Systems and space design are important considerations for safe care delivery. This special issue explores
how the built environment can affect safety in intensive ca…
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psnet.ahrq.gov/node/44132/psn-pdf
May 13, 2015 - Adverse outcomes: why bad things happen to good
people.
May 13, 2015
Sonnenberg A. Adverse outcomes: why bad things happen to good people. Clin Gastroenterol Hepatol.
2015;13(5):820-3.e1. doi:10.1016/j.cgh.2014.07.064.
https://psnet.ahrq.gov/issue/adverse-outcomes-why-bad-things-happen-good-people
This commentary…
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psnet.ahrq.gov/node/855002/psn-pdf
November 01, 2023 - Temporarily holding medication orders safely in order to
prevent patient harm.
November 1, 2023
ISMP Medication Safety Alert! Acute care edition. October 19, 2023;28(21):1-4.
https://psnet.ahrq.gov/issue/temporarily-holding-medication-orders-safely-order-prevent-patient-harm
Process disconnects can cause administr…
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psnet.ahrq.gov/node/45981/psn-pdf
June 21, 2017 - State sepsis mandates—a new era for regulation of
hospital quality.
June 21, 2017
Hershey TB, Kahn JM. State Sepsis Mandates - A New Era for Regulation of Hospital Quality. N Engl J
Med. 2017;376(24):2311-2313. doi:10.1056/NEJMp1611928.
https://psnet.ahrq.gov/issue/state-sepsis-mandates-new-era-regulation-hospital…
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psnet.ahrq.gov/node/44685/psn-pdf
November 18, 2015 - Root cause analyses of suicides of mental health clients.
November 18, 2015
Gillies D, Chicop D, O'Halloran P. Root Cause Analyses of Suicides of Mental Health Clients: Identifying
Systematic Processes and Service-Level Prevention Strategies. Crisis. 2015;36(5):316-324.
doi:10.1027/0227-5910/a000328.
https://psnet…
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psnet.ahrq.gov/node/72733/psn-pdf
February 10, 2021 - Start the year off right by preventing these top 10
medication errors and hazards from 2020.
February 10, 2021
ISMP Medication Safety Alert! Acute care edition. January 27, 2021;26(2).
https://psnet.ahrq.gov/issue/start-year-right-preventing-these-top-10-medication-errors-and-hazards-2020
Medication safety is chal…
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psnet.ahrq.gov/node/40181/psn-pdf
September 25, 2011 - The cost of serious fall-related injuries at three
midwestern hospitals.
September 25, 2011
Wong CA, Recktenwald AJ, Jones ML, et al. The cost of serious fall-related injuries at three Midwestern
hospitals. Jt Comm J Qual Patient Saf. 2011;37(2):81-87.
https://psnet.ahrq.gov/issue/cost-serious-fall-related-injurie…
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psnet.ahrq.gov/node/37671/psn-pdf
July 25, 2008 - Improving transfusion safety: implementation of a
comprehensive computerized bar code-based tracking
system for detecting and preventing errors.
July 25, 2008
Askeland RW, McGrane S, Levitt JS, et al. Improving transfusion safety: implementation of a
comprehensive computerized bar code-based tracking system for de…
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digital.ahrq.gov/ahrq-funded-projects/clinical-decision-support-optimizing-necrotizing-enterocolitis-prevention/final-report
January 01, 2023 - Clinical Decision Support Optimizing Necrotizing Enterocolitis Prevention Implementation in Neonatal Intensive Care Unit - Final Report
Citation
Gephart SM. Clinical Decision Support Optimizing Necrotizing Enterocolitis Prevention Implementation in Neonatal Intensive Care Unit - Final Report. (Prepare…
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digital.ahrq.gov/ahrq-funded-projects/shareable-interoperable-clinical-decision-support-older-adults-advancing-fall/citation/cds
January 01, 2023 - Clinical decision support for fall prevention: Defining end-user needs.
Citation
Rice H, Garabedian PM, Shear K, Bjarnadottir RI, Burns Z, Latham NK, Schentrup D, Lucero RJ, Dykes PC. Clinical decision support for fall prevention: Defining end-user needs. Appl Clin Inform. 2022 May;13(3):647-655. doi:…
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digital.ahrq.gov/ahrq-funded-projects/preventing-perioperative-medication-errors-and-adverse-drug-events-through-use/final-report
January 01, 2023 - Preventing Perioperative Medication Errors and Adverse Drug Events Through the Use of Clinical Decision Support - Final Report
Citation
Nanji K. Preventing Perioperative Medication Errors and Adverse Drug Events Through the Use of Clinical Decision Support - Final Report. (Prepared by Massachusetts Ge…
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psnet.ahrq.gov/node/74093/psn-pdf
November 17, 2021 - Prevent errors during emergency use of hypertonic
sodium chloride solutions.
November 17, 2021
ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4.
https://psnet.ahrq.gov/issue/prevent-errors-during-emergency-use-hypertonic-sodium-chloride-solutions
Delays in diagnosis and treatment duri…
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psnet.ahrq.gov/node/41835/psn-pdf
May 19, 2015 - Interventions for reducing wrong-site surgery and
invasive procedures.
May 19, 2015
Algie CM, Mahar RK, Wasiak J, et al. Interventions for reducing wrong-site surgery and invasive clinical
procedures. Cochrane Database Syst Rev. 2015;3)(3):CD009404. doi:10.1002/14651858.CD009404.pub3.
https://psnet.ahrq.gov/issue/…
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-qdr-appendixb-measure-category-7.pdf
January 01, 2023 - 2023 National Healthcare Quality and Disparities Report - Appendix B. Quality Trends and Disparities Tables: Care Coordination
AHRQ Publication No. 23(24)-0091-EF
December 2023
2023 National Healthcare Quality and Disparities Report
Appendix B. Quality Trends and Disparities Tables: Care Coordination
Care coor…
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www.ahrq.gov/hai/cusp/clabsi-final-companion/clabsicompapc.html
January 01, 2013 - Eliminating CLABSI, A National Patient Safety Imperative: Final Report Companion Guide
Appendix C. Article Exclusion List with Reason for Exclusion
Previous Page Next Page
Table of Contents
Eliminating CLABSI, A National Patient Safety Imperative: Final Report Companion Guide
Preface
Methods
P…
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psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle
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May 29, 2024
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January 01, 2012 - Studies have found that people with
ID receive less preventive care than the general population (Krahn … • Adequate preventive care can be compromised by a lack of social or financial support
(low SES), … "Evidence-based review of risk factors for geriatric depression and brief
preventive interventions."
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psnet.ahrq.gov/node/867804/psn-pdf
February 26, 2025 - Are We Safer Today?
February 26, 2025
Bates DW, Lee M, Mossburg SE. Are We Safer Today? PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/are-we-safer-today
In the 1999 report, To Err Is Human: Building a Safer Health System, the Institute of Medicine (now the
National Academy of Medicine) drew on two lar…