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psnet.ahrq.gov/node/44020/psn-pdf
March 25, 2015 - Wrong-site orthopedic operations on the extremities: the
Pennsylvania experience.
March 25, 2015
Clarke JR. PA-PSRS Patient Saf Advis. 2015;12:19-27.
https://psnet.ahrq.gov/issue/wrong-site-orthopedic-operations-extremities-pennsylvania-experience
Wrong-site surgeries are considered never events by the National Qu…
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psnet.ahrq.gov/node/36947/psn-pdf
September 09, 2011 - The safety of warfarin therapy in the nursing home
setting.
September 9, 2011
Gurwitz JH, Field T, Radford MJ, et al. The safety of warfarin therapy in the nursing home setting. Am J
Med. 2007;120(6):539-44.
https://psnet.ahrq.gov/issue/safety-warfarin-therapy-nursing-home-setting
The anticoagulant warfarin is co…
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psnet.ahrq.gov/node/35218/psn-pdf
August 07, 2018 - Building a Memory: Preventing Harm, Reducing Risks and
Improving Patient Safety.
August 7, 2018
Scobie S, Thomson R. London, UK : National Patient Safety Agency; 2005.
https://psnet.ahrq.gov/issue/building-memory-preventing-harm-reducing-risks-and-improving-patient-safety
Created in 2001 to institute changes in he…
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psnet.ahrq.gov/node/47093/psn-pdf
July 02, 2019 - Effects of computerized decision support system
implementations on patient outcomes in inpatient care: a
systematic review.
July 2, 2019
Varghese J, Kleine M, Gessner SI, et al. Effects of computerized decision support system implementations
on patient outcomes in inpatient care: a systematic review. J Am Med Info…
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psnet.ahrq.gov/node/45202/psn-pdf
October 08, 2016 - Towards international consensus on patient harm:
perspectives on pressure injury policy.
October 8, 2016
Jackson D, Hutchinson M, Barnason S, et al. Towards international consensus on patient harm:
perspectives on pressure injury policy. J Nurs Manag. 2016;24(7):902-914. doi:10.1111/jonm.12396.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/836995/psn-pdf
April 27, 2022 - Multifactorial interventions to reduce duration and
variability in delays to identification of serious injury after
falls in hospital inpatients.
April 27, 2022
Saleem J, Sarma D, Wright H, et al. Multifactorial interventions to reduce duration and variability in delays
to identification of serious injury after fa…
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psnet.ahrq.gov/node/45000/psn-pdf
August 15, 2016 - Medicare and Medicaid Programs; Hospital and Critical
Access Hospital (CAH) Changes to Promote Innovation,
Flexibility, and Improvement in Patient Care; Proposed
Rule.
June 29, 2016
Centers for Medicare & Medicaid Services. Fed Regist. 2016;81:39447-39480.
https://psnet.ahrq.gov/issue/medicare-and-medicaid-progra…
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psnet.ahrq.gov/node/867702/psn-pdf
September 01, 2021 - Toolkit To Reduce CAUTI and Other HAIs in Long-Term
Care Facilities.
September 1, 2021
Agency for Healthcare Research and Quality. Toolkit To Reduce CAUTI and Other HAIs in Long-Term
Care Facilities. September 2021.
https://psnet.ahrq.gov/issue/toolkit-reduce-cauti-and-other-hais-long-term-care-facilities
Cathete…
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digital.ahrq.gov/ahrq-funded-projects/shareable-interoperable-clinical-decision-support-older-adults-advancing-fall/final-report
January 01, 2023 - Shareable, Interoperable Clinical Decision Support for Older Adults: Advancing Fall Assessment and Prevention Patient-Centered Outcomes Research Findings into Diverse Primary Care Practices (ASPIRE) - Final Report
Citation
Dykes P. Shareable, Interoperable Clinical Decision Support for Older Adults: A…
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetysum.pdf
March 01, 2013 - Making Health Care Safer II, Executive Summary
Evidence-Based
Practice
Evidence-based Practice
Program
The Agency for Healthcare Research and
Quality (AHRQ), through its Evidence-
based Practice Centers (EPCs), sponsors
the development of evidence reports and
technology assessments to assist public-
and priv…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/047-evidence-behind-decolonization-strategies-notes.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
The Evidence Behind Decolonization Strategies for MRSA
ICU & Non-ICU
Slide Title and Commentary
Slide Number and Slide
Evidence Behind Decolonization Strategies for MRSA
SAY:
Welcome to this presentation on the current evidence behind decolonization strategies as part of an …
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psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
May 19, 2021 - SPOTLIGHT CASE
Postdischarge Follow-Up Phone Call
Citation Text:
Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Schol…
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psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
September 01, 2016 - SPOTLIGHT CASE
Multifactorial Medication Mishap
Citation Text:
Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Citation
Format:
Google Scholar BibTeX EndNot…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-218-osteoporosis-disposition-comments.pdf
April 23, 2019 - CER 218 Disposition of Comments: Long-Term Drug Therapy and Drug Holidays for Osteoporosis Fracture Prevention
Comparative Effectiveness Review Disposition of Public Reviewer Comments
Report
Research Review Title: Long-term Drug Therapy and Drug Holidays for Osteoporosis
Fracture Prevention: A Systematic Review
…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
January 01, 2014 - PowerPoint Presentation
Communication and Optimal Resolution (CANDOR): Grand Rounds Presentation
Presenter: Timothy B. McDonald, MD, JD
This presentation will introduce you to Communication and Optimal Resolution, or the CANDOR process. Some organizations struggle to improve the way they and their care teams respond…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/stroke-atrial-fibrillation_executive.pdf
August 01, 2013 - 1
Comparative Effectiveness Review
Number 123
Stroke Prevention in Atrial Fibrillation
Executive Summary
Background
Atrial Fibrillation and Stroke
Atrial fibrillation (AF) is a common type
of supraventricular tachyarrhythmia. While
a supraventricular tachyarrhythmia is a
tachycardic rhythm originating above t…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-finalreport-update-2021.pdf
January 01, 2021 - Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care: Final Report
Potentially Preventable Readmissions:
Conceptual Framework To Rethink
the Role of Primary Care
Final Report
This page is intentionally blank.
Potentially Preventable Readmissions:
Conceptual Framewo…
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psnet.ahrq.gov/node/73473/psn-pdf
January 01, 2022 - Improving safety recommendations before
implementation: a simulation-based event analysis to
optimize interventions designed to prevent recurrence of
adverse events.
July 7, 2021
Langevin M, Ward N, Fitzgibbons C, et al. Improving safety recommendations before implementation: a
simulation-based event analysis to …
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/113-staff-safety-assessment.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
Staff Safety Assessment
ICU & Non-ICU
Purpose of this form: This form is designed to tap into your experience to determine what risks are present in your unit that have jeopardized or could jeopardize patient safety.
Who should use this tool? Healthcare providers.
How to complete…
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www.ahrq.gov/hai/carb/index.html
May 01, 2022 - Combating Antibiotic-Resistant Bacteria
AHRQ works alongside Federal Agencies across the Government as part of the Task Force for Combating Antibiotic-Resistant Bacteria (CARB). The goal of this Task Force is to reduce antibiotic resistance by carrying out the actions described in the National Action Plan for C…