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psnet.ahrq.gov/issue/double-gloves-randomized-trial-evaluate-simple-strategy-reduce-contamination-operating-room
November 09, 2015 - Study
Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room.
Citation Text:
Birnbach DJ, Rosen LF, Fitzpatrick M, et al. Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room. …
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www.ahrq.gov/hai/cauti-tools/impl-guide/index.html
October 01, 2015 - Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Next Page
Table of Contents
Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Overview
Frameworks for Change and Improvement
Technical…
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psnet.ahrq.gov/issue/patient-safety-trauma-maximal-impact-management-errors-level-i-trauma-center
February 19, 2020 - Study
Patient safety in trauma: maximal impact management errors at a level I trauma center.
Citation Text:
Ivatury RR, Guilford K, Malhotra AK, et al. Patient safety in trauma: maximal impact management errors at a level I trauma center. J Trauma. 2008;64(2):265-270; discussion 270-27…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/059-nursing-protocol-nasal-mupirocin.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
Nursing Decolonization Protocol:
Nasal Mupirocin
ICU & Non-ICU
Note: Mupirocin should generally be chosen over iodophor when possible. A recent study showed a mupirocin & chlorhexidine gluconate (CHG) decolonization strategy to be more effective at reducing Staphylococcus aureus …
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/136-ss-premortem-tool.docx
April 01, 2025 - Comprehensive Unit-based Safety Program (CUSP) Premortem Project Assessment
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
Projects often fail, and many factors may contribute to this failure. Understanding potential implementation barriers and challenges before launching a …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/perioperative_asst.docx
December 01, 2017 - Tool: Perioperative Staff Safety Assessment
AHRQ Safety Program for Surgery
Perioperative Staff Safety Assessment
Introduction
Problem Statement
One of the strongest determinants of safety culture is whether local and hospital leadership respond to staff patient safety concerns. Frontline providers understand patie…
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psnet.ahrq.gov/issue/incomplete-care-trail-flaws-system
February 17, 2011 - Commentary
Incomplete care—on the trail of flaws in the system.
Citation Text:
Gandhi TK, Zuccotti G, Lee TH. Incomplete care--on the trail of flaws in the system. N Engl J Med. 2011;365(6):486-8. doi:10.1056/NEJMp1106313.
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psnet.ahrq.gov/issue/pharmacist-transition-care-services-improve-patient-satisfaction-and-decrease-hospital
March 11, 2020 - Study
Pharmacist transition-of-care services improve patient satisfaction and decrease hospital readmissions.
Citation Text:
Pharmacist transition-of-care services improve patient satisfaction and decrease hospital readmissions. March KL, Peters MJ, Finch CK, et al. J Pharm Pract. 2…
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psnet.ahrq.gov/issue/eacts-guidelines-use-patient-safety-checklists
October 31, 2012 - Commentary
EACTS guidelines for the use of patient safety checklists.
Citation Text:
Clark SC, Dunning J, Alfieri OR, et al. EACTS guidelines for the use of patient safety checklists. Eur J Cardiothorac Surg. 2012;41(5):993-1004. doi:10.1093/ejcts/ezs009.
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psnet.ahrq.gov/issue/unintentionally-retained-guidewires-descriptive-study-73-sentinel-events
April 27, 2019 - Study
Unintentionally retained guidewires: a descriptive study of 73 sentinel events.
Citation Text:
Steelman VM, Thenuwara K, Shaw C, et al. Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events. Jt Comm J Qual Saf. 2019;45(2):81-90. doi:10.1016/j.jcjq.2018.08.0…
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psnet.ahrq.gov/issue/pharmacy-dispensing-errors-claims-study-emphasizes-need-systematic-vigilance
April 06, 2022 - Newspaper/Magazine Article
Pharmacy dispensing errors: claims study emphasizes need for systematic vigilance.
Citation Text:
Pharmacy dispensing errors: claims study emphasizes need for systematic vigilance. Webb J. Drug Topics. March 10, 2015.
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psnet.ahrq.gov/issue/frequency-inappropriate-medical-exceptions-quality-measures
July 29, 2020 - Study
Frequency of inappropriate medical exceptions to quality measures.
Citation Text:
Persell SD, Dolan NC, Friesema EM, et al. Frequency of inappropriate medical exceptions to quality measures. Ann Intern Med. 2010;152(4):225-31. doi:10.7326/0003-4819-152-4-201002160-00007.
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psnet.ahrq.gov/issue/safe-handover
December 21, 2017 - Commentary
Safe handover.
Citation Text:
Merten H, van Galen LS, Wagner C. Safe handover. BMJ. 2017;359:j4328. doi:10.1136/bmj.j4328.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/issue/sudden-death-lung-embolism-after-inadvertent-infusion-zinc-oxide-shake-lotion
January 12, 2022 - Commentary
A sudden death with lung embolism after inadvertent infusion of zinc oxide shake lotion.
Citation Text:
Pragst F, Correns A, Priem F, et al. A sudden death with lung embolism after inadvertent infusion of zinc oxide shake lotion. Forensic Sci Int. 2007;170(2-3):207-12.
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psnet.ahrq.gov/issue/linking-nurse-characteristics-team-member-effectiveness-practice-environment-and-medication
May 14, 2008 - Study
Linking nurse characteristics, team member effectiveness, practice environment, and medication error incidence.
Citation Text:
Fasolino T, Snyder R. Linking nurse characteristics, team member effectiveness, practice environment, and medication error incidence. J Nurs Care Qual. 2…
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psnet.ahrq.gov/issue/interrater-agreement-standard-scheme-classifying-medication-errors
September 30, 2020 - Study
Interrater agreement with a standard scheme for classifying medication errors.
Citation Text:
Forrey RA, Pedersen CA, Schneider PJ. Interrater agreement with a standard scheme for classifying medication errors. Am J Health Syst Pharm. 2007;64(2):175-81.
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psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-overview-qi
November 08, 2023 - Commentary
Patient safety and quality improvement: an overview of QI.
Citation Text:
Schriefer J, Leonard M. Patient safety and quality improvement: an overview of QI. Pediatr Rev. 2012;33(8):353-9; quiz 359-60. doi:10.1542/pir.33-8-353.
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psnet.ahrq.gov/issue/nature-causes-and-consequences-unintended-events-surgical-units
September 07, 2016 - Study
Nature, causes and consequences of unintended events in surgical units.
Citation Text:
van Wagtendonk I, Smits M, Merten H, et al. Nature, causes and consequences of unintended events in surgical units. Br J Surg. 2010;97(11):1730-40. doi:10.1002/bjs.7201.
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psnet.ahrq.gov/issue/application-surgical-safety-standards-robotic-surgery-five-principles-ethics-nonmaleficence
October 19, 2022 - Review
Application of surgical safety standards to robotic surgery: five principles of ethics for nonmaleficence.
Citation Text:
Larson JA, Johnson MH, Bhayani SB. Application of surgical safety standards to robotic surgery: five principles of ethics for nonmaleficence. J Am Coll Surg. …
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psnet.ahrq.gov/issue/reducing-medication-errors-using-applied-technology
January 07, 2011 - Commentary
Reducing medication errors by using applied technology.
Citation Text:
Caesar BR, Hutchinson B. Reducing medication errors by using applied technology. Nursing (Brux). 2006;36(8):24-25.
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