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psnet.ahrq.gov/node/49770/psn-pdf
September 01, 2016 - Wrong-Time Error With High-Alert Medication
September 1, 2016
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
The Case
A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…
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psnet.ahrq.gov/web-mm/misread-label
August 28, 2024 - Misread Label
Citation Text:
Franklin BD. Misread Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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psnet.ahrq.gov/web-mm/mark-my-tooth
June 01, 2014 - Mark My Tooth
Citation Text:
Smith RA. Mark My Tooth. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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D…
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www.ahrq.gov/hai/tools/mvp/modules/technical/subglottic-fac-guide.html
January 01, 2017 - Benefits of Subglottic Secretion Drainage Endotracheal Tubes: Facilitator Guide
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: Benefits of Subglottic Secretion Drainage Endotracheal Tubes
Say:
In this module, you will learn about the benefits of subglottic secretion drainage endotrach…
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www.ahrq.gov/nursing-home/resources/search.html?page=4
January 01, 2022 - COVID-19 Resources Catalog for Nursing Homes
AHRQ provided free training and mentorship to nursing homes across the country through the National Nursing Home COVID-19 Action Network . The Network supported the implementation of evidence-based prevention and safety practices within nursing homes to protect residents…
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www.ahrq.gov/es/nursing-home/resources/search.html?page=4
January 01, 2022 - COVID-19 Resources Catalog for Nursing Homes
AHRQ provided free training and mentorship to nursing homes across the country through the National Nursing Home COVID-19 Action Network . The Network supported the implementation of evidence-based prevention and safety practices within nursing homes to protect residents…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-mupirocin.docx
March 01, 2022 - FAQs (Staff): Nasal Mupirocin for MRSA-Positive Patients With Devices
Decolonization of
Non-ICU Patients With Devices
Section 14-2 – Addressing Questions Asked by Staff:
Nasal Mupirocin for MRSA Carriers With Devices
What is mupirocin and how safe is it?
Mupirocin is a topical antibiotic ointment to prevent infe…
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www.ahrq.gov/hai/tools/surgery/modules/on-boarding/ssi-investigation-slides.html
December 01, 2017 - Performing SSI Investigations: Slide Presentation
AHRQ Safety Program for Surgery
Slide 1: AHRQ Safety Program for Surgery—Onboarding
Performing an SSI Investigation
Slide 2: Learning Objectives
After this session, you will be able to–
Explain the difference between process and outcome data.
D…
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psnet.ahrq.gov/node/33591/psn-pdf
March 15, 2025 - Triggers and Trigger Tools
March 15, 2025
Triggers and Trigger Tools. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/triggers-and-trigger-tools
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safet…
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psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
January 29, 2021 - Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery
Citation Text:
Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qual…
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www.ahrq.gov/research/findings/final-reports/stpra/stpra3.html
April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Chapter 3. Risk-Informed Interventions
Previous Page Next Page
Table of Contents
Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Executive Summary
Chapter 1. Introduction
Chapt…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/building-team-040814.pptx
January 01, 2013 - Nursing Intervention to Remove Non-necessary Urinary Catheters
Mohamad Fakih, MD, MPH
Professor of Medicine
Wayne State University School of Medicine
Medical Director, Infection Prevention and Control
St. John Hospital and Medical Center
Barbara Lucas, MD, MHSA
Project Consultant
Michigan Health & Hospital Associatio…
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psnet.ahrq.gov/node/49722/psn-pdf
December 01, 2014 - Medical Devices in the "Wild"
December 1, 2014
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/medical-devices-wild
The Case
A 75-year-old man with a history of congestive heart failure (CHF), coronary artery disease, diabetes,
chronic pain, arthritis, and…
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psnet.ahrq.gov/web-mm/dangerous-dapsone
January 10, 2011 - Dangerous Dapsone
Citation Text:
Bookwalter T. Dangerous Dapsone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
February 01, 2012 - An Untimely End Despite End-of-Life Care Planning
Citation Text:
Elia G, Barbour S, Anderson WG. An Untimely End Despite End-of-Life Care Planning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Lapane.pdf
March 09, 2005 - Technology for Improving Medication Monitoring in Nursing Homes
401
Technology for Improving Medication
Monitoring in Nursing Homes
Kate L. Lapane, Kathleen Cameron, Janice Feinberg
Abstract
A 1997 report entitled Prescription Drug Use in Nursing Homes, by the
Department of Health and Human Services’ Office…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/functspecs.pdf
March 22, 2014 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Functional Specifications
1
AHRQ’s Safety Program for Nursing Homes: On-Time
Pressure Ulcer Prevention
Functional Specifications
1. General Information
1.1. Background
The Agency for Health Care Research and Quality (AHRQ) developed…
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psnet.ahrq.gov/node/39116/psn-pdf
April 30, 2014 - Diagnostic error in medicine: analysis of 583 physician-
reported errors.
April 30, 2014
Schiff G, Hasan O, Kim S, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors.
Arch Intern Med. 2009;169(20):1881-1887. doi:10.1001/archinternmed.2009.333.
https://psnet.ahrq.gov/issue/diagnostic-err…
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psnet.ahrq.gov/node/44026/psn-pdf
November 03, 2015 - Effect of a postdischarge virtual ward on readmission or
death for high-risk patients: a randomized clinical trial.
November 3, 2015
Dhalla IA, O'Brien T, Morra D, et al. Effect of a postdischarge virtual ward on readmission or death for high-
risk patients: a randomized clinical trial. JAMA. 2014;312(13):1305-12. …
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psnet.ahrq.gov/issue/creating-culture-safety-opioid-prescribing-handbook-healthcare-executives
May 01, 2023 - Toolkit
Creating a Culture of Safety for Opioid Prescribing: A Handbook for Healthcare Executives.
Citation Text:
Centers for Disease Control and Prevention (CDC); 2021. Creating a Culture of Safety for Opioid Prescribing: A Handbook for Healthcare Executives.
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