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psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-errors-operating-room
January 29, 2021 - Is that solution for IV or irrigation?: Fluid administration errors in the operating room.
Citation Text:
Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-insertion-notes.docx
April 01, 2022 - Central Venous Catheter Insertion Bundle Facilitator Notes
CLABSI Module:
Central Venous Catheter Insertion
Facilitator Guide
Slide Number and Image
This module, titled Central Venous Catheter Insertion, is part of the Agency for Healthcare Research and Quality’s Safety Program for Intensive Care Units (ICUs) t…
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/venous-thromboembolism-1.pdf
March 01, 2020 - Making Healthcare Safer Practices: 16. Venous Thromboembolism
Venous Thromboembolism 16-1
16. Venous Thromboembolism
Eleanor Fitall, M.P.H., and Kendall K. Hall, M.D., M.S.
Introduction
Background
Venous thromboembolism (VTE) is a disorder that includes deep vein thrombosis (DVT) and pulmonary
embolism (PE). …
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www.ahrq.gov/sites/default/files/2025-02/peterson-report.pdf
January 01, 2025 - Final Progress Report: Detection, Education, Research, and Decolonization without Isolation in Long-term Care (DERAIL MRSA)
Title: Detection, Education, Research, and Decolonization
without Isolation in Long-term Care (DERAIL MRSA)
Principal Investigator: Lance R. Peterson, MD
Team Members: Ari Robicsek, MD, Jenni…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/stroke-atrial-fibrillation_research-protocol.pdf
January 30, 2012 - Evidence-based Practice Center Systematic Review Protocol
Source: www.effectivehealthcare.ahrq.gov
Published Online: January 30, 2012
Page 1
Evidence-based Practice Center Systematic Review Protocol
Project Title: Stroke Prevention in Atrial Fibrillation
I. Background and Objectives fo…
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psnet.ahrq.gov/node/42270/psn-pdf
December 31, 2014 - Relationship between medication event rates and the
Leapfrog computerized physician order entry evaluation
tool.
December 31, 2014
Leung AA, Keohane C, Lipsitz S, et al. Relationship between medication event rates and the Leapfrog
computerized physician order entry evaluation tool. J Am Med Info Asso. 2013;20(e1):…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/058-patient-instructions-iodophor.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Patient Info Sheet: Preoperative Nasal Decolonization With Iodophor
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
What Is Nasal Decolonization?
Some bacteria can live inside your nostrils for a long time. Normally, the…
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www.ahrq.gov/hai/cusp/clabsi-neonatal/nclabsi8.html
January 01, 2013 - Eliminating CLABSI, A National Patient Safety Imperative: Neonatal CLABSI Prevention
Next Steps
Previous Page
Table of Contents
Eliminating CLABSI, A National Patient Safety Imperative: Neonatal CLABSI Prevention
Executive Summary
Introduction & Objectives
Methods
Data Collection and Analy…
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psnet.ahrq.gov/node/37707/psn-pdf
March 02, 2011 - Bar-coding surgical sponges to improve safety: a
randomized controlled trial.
March 2, 2011
Greenberg CC, Diaz-Flores R, Lipsitz SR, et al. Bar-coding Surgical Sponges To Improve Safety. Ann
Surg. 2009;247(4). doi:10.1097/sla.0b013e3181656cd5.
https://psnet.ahrq.gov/issue/bar-coding-surgical-sponges-improve-safe…
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psnet.ahrq.gov/node/41610/psn-pdf
January 25, 2017 - Adverse events among children in Canadian hospitals:
the Canadian Paediatric Adverse Events Study.
January 25, 2017
Matlow A, Baker R, Flintoft V, et al. Adverse events among children in Canadian hospitals: the Canadian
Paediatric Adverse Events Study. CMAJ. 2012;184(13):E709-718. doi:10.1503/cmaj.112153.
https://…
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psnet.ahrq.gov/node/42458/psn-pdf
February 13, 2014 - Human factors and ergonomics as a patient safety
practice.
February 13, 2014
Carayon P, Xie A, Kianfar S. Human factors and ergonomics as a patient safety practice. BMJ Qual Saf.
2014;23(3):196-205. doi:10.1136/bmjqs-2013-001812.
https://psnet.ahrq.gov/issue/human-factors-and-ergonomics-patient-safety-practice
As…
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psnet.ahrq.gov/node/46560/psn-pdf
January 24, 2019 - The hidden cost of regulation: the administrative cost of
reporting serious reportable events.
January 24, 2019
Blanchfield BB, Acharya B, Mort E. The Hidden Cost of Regulation: The Administrative Cost of Reporting
Serious Reportable Events. Jt Comm J Qual Patient Saf. 2018;44(4):212-218.
doi:10.1016/j.jcjq.2017.0…
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psnet.ahrq.gov/node/43064/psn-pdf
January 01, 2015 - Leadership, safety climate, and continuous quality
improvement: impact on process quality and patient
safety.
December 12, 2014
McFadden KL, Stock GN, Gowen CR. Leadership, safety climate, and continuous quality improvement:
impact on process quality and patient safety. Health Care Manage Rev. 2015;40(1):24-34.
d…
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psnet.ahrq.gov/node/72467/psn-pdf
November 18, 2020 - Higher incidence of adverse events in isolated patients
compared with non-isolated patients: a cohort study.
November 18, 2020
Jiménez-Pericás F, Gea Velázquez de Castro MT, Pastor-Valero M, et al. Higher incidence of adverse
events in isolated patients compared with non-isolated patients: a cohort study. BMJ Open.…
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psnet.ahrq.gov/node/845640/psn-pdf
March 08, 2023 - Effect of Patient and Family Centered I-PASS on adverse
event rates in hospitalized children with complex chronic
conditions.
March 8, 2023
Kuzma N, Khan A, Rickey L, et al. Effect of Patient and Family Centered I?PASS on adverse event rates in
hospitalized children with complex chronic conditions. J Hosp Med. 202…
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psnet.ahrq.gov/node/41369/psn-pdf
May 29, 2015 - Cognitive interventions to reduce diagnostic error: a
narrative review.
May 29, 2015
Graber ML, Kissam S, Payne VL, et al. Cognitive interventions to reduce diagnostic error: a narrative
review. BMJ Qual Saf. 2012;21(7):535-557. doi:10.1136/bmjqs-2011-000149.
https://psnet.ahrq.gov/issue/cognitive-interventions-re…
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psnet.ahrq.gov/node/73109/psn-pdf
April 07, 2021 - Common general surgical never events: analysis of NHS
England never event data.
April 7, 2021
Omar I, Singhal R, Wilson M, et al. Common general surgical never events: analysis of NHS England never
event data. Int J Qual Health Care. 2021;33(1):mzab045. doi:10.1093/intqhc/mzab045.
https://psnet.ahrq.gov/issue/comm…
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psnet.ahrq.gov/node/74752/psn-pdf
February 07, 2022 - Coronavirus disease 2019 (COVID-19) pandemic, central-
line-associated bloodstream infection (CLABSI), and
catheter-associated urinary tract infection (CAUTI): the
urgent need to refocus on hardwiring prevention efforts.
February 7, 2022
Fakih MG, Bufalino A, Sturm L, et al. Coronavirus disease 2019 (COVID-19) pan…
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psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
December 02, 2020 - SPOTLIGHT CASE
The Lost Start Date: an Unknown Risk of E-prescribing
Citation Text:
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Cit…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/functspecs2.html
December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention
Functional Specifications (continued)
2.0. Pressure Ulcer Prevention Reports
The reports included in On-Time Pressure Ulcer Prevention and described in this document are listed in the table below.
On-Time Pressure Ulcer Prevention …