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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.
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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 …
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/046-ss-faqs-staff-decolonization-chg-nasal.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Preoperative Decolonization
Staff – Frequently Asked Questions
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
These are frequently asked questions for staff about skin decolonization with chlorhexidine gluconate (CHG) an…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/talking-points-chg-bathing.pdf
March 01, 2022 - Talking Points for Chlorhexidine Bathing
Decolonization of
Non-ICU Patients With Devices
Section 14-8 – Talking Points for Chlorhexidine Bathing
Patients may have questions regarding chlorhexidine (CHG) bathing. Below are some suggested
responses to common patient questions.
REMEMBER: Your enthusias…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 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.4n
Selected Best Practices and Suggestions for Improvement
IQI: Mortality Review of Select Procedures and Conditions
Why Focus on Mortality Review? …
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psnet.ahrq.gov/web-mm/chemotherapy-extravasation
September 24, 2010 - Chemotherapy Extravasation
Citation Text:
Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
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psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - Patient Safety Indicators
Citation Text:
Tokareva I, Romano P. Patient Safety Indicators.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
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psnet.ahrq.gov/node/49869/psn-pdf
July 02, 2019 - Failure to Rescue the Mother
July 2, 2019
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/failure-rescue-mother
The Case
A 27-year-old woman, G5 P2 A2, was first admitted to the hospital at 25 weeks of pregnancy for vaginal
bleeding. An …
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/facslides.html
December 01, 2017 - On-Time Pressure Ulcer Healing: Facilitator Training Slide Presentation
AHRQ’s Safety Program for Nursing Homes
Text version of slide presentation.
Slide 1: Overview of On-Time
AHRQ’s Safety Program for Nursing Homes:
On-Time Pressure Ulcer Healing Facilitator Training
Slide 2: On-Time Pressure Ulcer…
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psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx
Spotlight
When the Lytes Go Out: A Case
of Inpatient Cardiac Arrest
Source and Credits
• This presentation is based on the September 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psne…
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - National Patient Safety Goals
Citation Text:
Shaikh U. National Patient Safety Goals. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
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psnet.ahrq.gov/primer/opioid-safety
December 15, 2024 - Opioid Safety
Citation Text:
Opioid Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Download Ci…
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psnet.ahrq.gov/web-mm/confusion-acetaminophen
December 01, 2009 - Confusion With Acetaminophen
Citation Text:
Heubi JE. Confusion With Acetaminophen. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
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psnet.ahrq.gov/node/72516/psn-pdf
November 25, 2020 - Premature Closure: Was It Just Syncope?
November 25, 2020
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
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psnet.ahrq.gov/node/866261/psn-pdf
July 10, 2024 - Missed Compartment Syndrome after Steep Lithotomy
Position for Laparoscopic Gynecological Surgery
July 10, 2024
Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic
Gynecological Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/missed-compartment-syndrome…