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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4x_combo_pdi12-crbsi-bestpractices.pdf
May 17, 2016 - Selected Best Practices and Suggestions for Improvement
Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4x
Selected Best Practices and Suggestions for Improvement
PDI 12: Central Venous Catheter (CVC)-Related Bloodstream Infection Rate (BSIs)
Why focus on c…
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psnet.ahrq.gov/node/866826/psn-pdf
September 25, 2024 - Hypoxic Gas Supply from Cross-Connected Pipelines
September 25, 2024
Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
The Case
An 8-year-old boy with no significant past medical…
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psnet.ahrq.gov/node/49392/psn-pdf
April 01, 2003 - Another Fall
April 1, 2003
Bogardus SG. Another Fall. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/another-fall
Case Objectives
List risk factors for falls in hospitalized patients
Understand appropriate use of restraints
Identify system issues contributing to falls in hospitalized patients
Case & Comm…
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psnet.ahrq.gov/node/49500/psn-pdf
January 01, 2006 - Confusion With Acetaminophen
January 1, 2006
Heubi JE. Confusion With Acetaminophen. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/confusion-acetaminophen
The Case
Parents brought their 5-year-old son to the emergency department (ED) with a 24-hour history of fever,
cough, and frontal headache. Physical e…
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psnet.ahrq.gov/node/49425/psn-pdf
November 01, 2003 - Misread Label
November 1, 2003
Franklin BD. Misread Label. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/misread-label
The Case
An infant was born with sluggish respirations. During labor the infant’s mother had received meperidine
[Demerol, a pain medication], a narcotic with a half-life of 2.5-4.0 hours…
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psnet.ahrq.gov/node/60580/psn-pdf
January 01, 2022 - Sustaining the gains: a 7-year follow-through of a
hospital-wide patient safety improvement project on
hospital-wide adverse event outcomes and patient safety
culture.
June 10, 2020
Sim MA, Ti LK, Mujumdar S, et al. Sustaining the gains: a 7-year follow-through of a hospital-wide patient
safety improvement projec…
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www.ahrq.gov/hai/cusp/modules/patient-family-engagement/index.html
July 01, 2018 - Patient and Family Engagement
The Patient and Family Engagement module of the CUSP Toolkit focuses on making sure patients and their family members understand what is happening during the patient's hospital stay, are active participants in the patient's care, and are prepared for discharge.
This module expl…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/044-ss-preop-dos-donts.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Decolonization With Pre-Impregnated Wipes in the Preoperative Area:
Do’s and Don’ts for Surgical Staff
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
To prevent surgical site infections (SSI), follow these dire…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/handouts/staff-mupirocin.pdf
March 01, 2022 - MRSA Carriers With Devices: Prevent Infections During the Hospital Stay How To Apply Nasal Mupirocin
AHRQ Pub. No. 20(22)-0036
March 2022
STAFF MRSA Carriers With Devices: Prevent Infections During the Hospital Stay
How To Apply Nasal Mupirocin
Apply nasal mupirocin ointment twice daily for 5 days…
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psnet.ahrq.gov/node/39000/psn-pdf
September 01, 2016 - Clinicians' assessments of electronic medication safety
alerts in ambulatory care.
September 1, 2016
Weingart SN, Simchowitz B, Shiman L, et al. Clinicians' assessments of electronic medication safety alerts
in ambulatory care. Arch Intern Med. 2009;169(17):1627-1632. doi:10.1001/archinternmed.2009.300.
https://ps…
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psnet.ahrq.gov/node/841142/psn-pdf
December 07, 2022 - Experience of hospital-initiated medication changes in
older people with multimorbidity: a multicentre mixed-
methods study embedded in the OPtimising thERapy to
prevent Avoidable hospital admissions in Multimorbid
older people (OPERAM) trial.
December 7, 2022
Thevelin S, Pétein C, Metry B, et al. Experience of h…
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psnet.ahrq.gov/node/72726/psn-pdf
February 10, 2021 - Wrong administration route of medications in the
domestic setting: a review of an underestimated public
health topic.
February 10, 2021
Gualano MR, Lo Moro G, Voglino G, et al. Wrong administration route of medications in the domestic
setting: a review of an underestimated public health topic. Expert Opin Pharmaco…
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psnet.ahrq.gov/node/73509/psn-pdf
July 21, 2021 - NHS ‘Learning from Deaths’ reports: a qualitative and
quantitative document analysis of the first year of a
countrywide patient safety programme.
July 21, 2021
Brummell Z, Vindrola-Padros C, Braun D, et al. NHS ‘Learning from Deaths’ reports: a qualitative and
quantitative document analysis of the first year of a …
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psnet.ahrq.gov/node/39917/psn-pdf
October 13, 2010 - Prevalence of adverse events in pediatric intensive care
units in the United States.
October 13, 2010
Agarwal S, Classen D, Larsen G, et al. Prevalence of adverse events in pediatric intensive care units in the
United States. Pediatr Crit Care Med. 2010;11(5):568-578. doi:10.1097/PCC.0b013e3181d8e405.
https://psne…
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psnet.ahrq.gov/node/61004/psn-pdf
October 07, 2020 - National Nursing Home COVID Action Network.
October 7, 2020
Rockville, MD: Agency for Healthcare Research and Quality; September 2020.
https://psnet.ahrq.gov/issue/national-nursing-home-covid-action-network
Nursing home residents are especially vulnerable to COVID-19 due to their age, and communal living
condition…
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psnet.ahrq.gov/node/48101/psn-pdf
August 14, 2019 - Partnering with families and patient advocates: another
line of defense in adverse event surveillance.
August 14, 2019
ISMP Medication Safety Alert! Acute Care Edition. August 1, 2019;24.
https://psnet.ahrq.gov/issue/partnering-families-and-patient-advocates-another-line-defense-adverse-event-
surveillance
Having…
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psnet.ahrq.gov/node/836772/psn-pdf
March 23, 2022 - Error reduction in trauma care: lessons from an
anonymized, national, multicenter mortality reporting
system.
March 23, 2022
Hamad DM, Mandell SP, Stewart RM, et al. Error reduction in trauma care: Lessons from an anonymized,
national, multicenter mortality reporting system. J Trauma Acute Care Surg. 2022;92(3):47…
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psnet.ahrq.gov/node/40390/psn-pdf
February 03, 2015 - The $17.1 billion problem: the annual cost of measurable
medical errors.
February 3, 2015
Van Den Bos J, Rustagi K, Gray T, et al. The $17.1 Billion Problem: The Annual Cost Of Measurable
Medical Errors. Health Aff. 2011;30(4):596-603. doi:10.1377/hlthaff.2011.0084.
https://psnet.ahrq.gov/issue/171-billion-problem…
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psnet.ahrq.gov/node/45737/psn-pdf
December 22, 2017 - Nursing skill mix in European hospitals: cross-sectional
study of the association with mortality, patient ratings,
and quality of care.
December 22, 2017
Aiken LH, Sloane DM, Griffiths P, et al. Nursing skill mix in European hospitals: cross-sectional study of the
association with mortality, patient ratings, and q…
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psnet.ahrq.gov/node/851352/psn-pdf
July 12, 2023 - Identifying a list of healthcare 'never events' to effect
system change: a systematic review and narrative
synthesis.
July 12, 2023
Bowman CL, De Gorter R, Zaslow J, et al. Identifying a list of healthcare ‘never events’ to effect system
change: a systematic review and narrative synthesis. BMJ Open Qual. 2023;12(2…