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psnet.ahrq.gov/issue/epidemiology-medical-error
March 29, 2012 - Commentary
Classic
Epidemiology of medical error.
Citation Text:
Weingart SN, Wilson R, Gibberd RW, et al. Epidemiology of medical error. BMJ. 2000;320(7237):774-7.
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Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML E…
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psnet.ahrq.gov/issue/antimicrobial-stewardship-another-focus-patient-safety
May 29, 2024 - Review
Antimicrobial stewardship: another focus for patient safety?
Citation Text:
Tamma PD, Holmes A, Ashley ED. Antimicrobial stewardship: another focus for patient safety? Curr Opin Infect Dis. 2014;27(4):348-55. doi:10.1097/QCO.0000000000000077.
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DO…
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psnet.ahrq.gov/issue/design-and-implementation-infection-prevention-program-risk-management-managing-high-level
December 18, 2014 - Study
Design and implementation of the infection prevention program into risk management: managing high level disinfection and sterilization in the outpatient setting.
Citation Text:
Sweet W, Snyder D, Raymond M. Design and implementation of the infection prevention program into risk man…
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psnet.ahrq.gov/issue/inpatient-suicide-general-hospital
May 27, 2020 - Study
Inpatient suicide in a general hospital.
Citation Text:
Cheng I-C, Hu F-C, Tseng M-CM. Inpatient suicide in a general hospital. Gen Hosp Psychiatry. 2009;31(2):110-5. doi:10.1016/j.genhosppsych.2008.12.008.
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psnet.ahrq.gov/issue/prevalence-and-characteristics-interruptions-and-distractions-during-surgical-counts
March 09, 2016 - Study
Prevalence and characteristics of interruptions and distractions during surgical counts.
Citation Text:
Bubric KA, Biesbroek SL, Laberge JC, et al. Prevalence and characteristics of interruptions and distractions during surgical counts. Jt Comm J Qual Patient Saf. 2021;47(9):556-56…
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psnet.ahrq.gov/issue/discrepant-advanced-directives-and-code-status-orders-preventable-medical-error
October 31, 2018 - Journal Article
Discrepant advanced directives and code status orders: a preventable medical error.
Citation Text:
Meisenberg B, Zaidi S, Franks L, et al. Discrepant Advanced Directives and Code Status Orders: A Preventable Medical Error. J Hosp Med. 2019;14(10):716-718. doi:10.12788/jhm…
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psnet.ahrq.gov/issue/patient-safety-climate-variation-perceptions-infection-preventionists-and-quality-directors
January 09, 2011 - Study
Patient safety climate: variation in perceptions by infection preventionists and quality directors.
Citation Text:
Nelson S, Stone PW, Jordan S, et al. Patient safety climate: variation in perceptions by infection preventionists and quality directors. Interdiscip Perspect Infect …
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psnet.ahrq.gov/issue/learning-preventable-adverse-events-health-care-organizations-development-multilevel-model
June 28, 2010 - Commentary
Learning from preventable adverse events in health care organizations: development of a multilevel model of learning and propositions.
Citation Text:
Chuang Y-T, Ginsburg LR, Berta WB. Learning from preventable adverse events in health care organizations: development of a mu…
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psnet.ahrq.gov/issue/quality-journey-ascension-health-how-weve-prevented-least-1500-avoidable-deaths-year-and-aim
June 06, 2018 - Commentary
The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths a year—and aim to do even better.
Citation Text:
Pryor D, Hendrich A, Henkel RJ, et al. The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths…
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psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
January 01, 2019 - Spotlight
Missed Opportunities for Suicide
Risk Assessment
Source and Credits
• This presentation is based on the November 2019 AHRQ WebM&M
Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Glen Xiong, MD & Debra Kahn, MD
○ Editors in Chief, AHRQ We…
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www.ahrq.gov/hai/tools/mvp/modules/vae/overview-off-ventilator-slides.html
February 01, 2017 - Overview: Getting Patients Off the Ventilator Faster: Slide Presentation
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients
Overview: Getting Patients Off the Ventilator Faster
Slide 2: Learning Objectives
After this session, yo…
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www.ahrq.gov/sites/default/files/2024-10/smucker-report.pdf
January 01, 2024 - Final Progress Report: Patient Safety in Hospice Care
AHRQ Grant Final Progress Report
Title of Project: Patient Safety in Hospice Care
Principal Investigator: Douglas R. Smucker, MD, MPH, Adjunct Professor, University
of Cincinnati Department of Family and Community Medicine
Team Members:
• Nancy Elder, MD, Ass…
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psnet.ahrq.gov/print/pdf/node/867461
January 31, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Patient and Family Engagement in Long
Term Care
Curated Library
Foundations
Long-term Care and Patient Safety
Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA | April, 10 2024
A large and growing number of Americans require care in skilled nursin…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-iv-patient-safety-practices-year-2.pdf
May 01, 2025 - Making Healthcare Safer IV: Summary of Findings on Patient Safety Practices and Ratings by a Technical Expert Panel, 2024-2025
Making Healthcare Safer IV
Making Healthcare Safer IV: Summary of Findings
on Patient Safety Practices and Ratings by a
Technical Expert Panel, 2024-2025
Prepared for:
Agen…
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www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/heartfailure.pdf
June 02, 2025 - Heart Failure: Most Common and Expensive Reason for Preventable Hospital Stays, 2017
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www.ahrq.gov/research/findings/final-reports/ssi/ssiapr.html
April 01, 2018 - Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection
Appendix R. Infection Prevention Support Tool
Previous Page Next Page
Table of Contents
Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection
Executive Summary
Chapter …
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www.ahrq.gov/hai/cauti-tools/impl-guide/implementation-guide-appendix-k.html
October 01, 2015 - Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Appendix K. Infographic Poster on CAUTI Prevention
Previous Page Next Page
Table of Contents
Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation G…
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www.ahrq.gov/ncepcr/communities/pbrn/registry/kansas-patients-and-providers-engaged-prevention-research.html
January 16, 2013 - Kansas Patients and Providers Engaged in Prevention Research
Status:
Active
Registered Date:
January 16, 2013
PBRN Acronym:
KPPEPR
PBRN Type:
Family Medicine Network (at least 75% are Family Medicine Clinicians)
Network Category:
Established
City:
Kansas City
…
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www.ahrq.gov/sites/default/files/2024-11/lamb-report.pdf
January 01, 2024 - Final Progress Report: Automated Image Analysis for the Prevention of Radiotherapy Delivery Errors
Final Report: Automated Image Analysis for the Prevention of Radiotherapy Delivery Errors
Resubmission Date 1-10-2024
Title of Project: Automated I…
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www.ahrq.gov/funding/grantee-profiles/grtprofile-nishisaki.html
July 01, 2025 - Grantee Profile
Eliminating Preventable Harms During Pediatric Intubation
Akira Nishisaki, M.D., M.S.C.E. Attending Physician, Critical Care Medicine, Children’s Hospital of Philadelphia Co-Medical Director for Center for Simulation, Advanced Education and Innovation, Children’s Hospital of Philadelphia Cha…