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psnet.ahrq.gov/primer/never-events
June 15, 2024 - Never Events
Citation Text:
Never Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/33872/psn-pdf
January 01, 2018 - Update: Patient Engagement in Safety
January 1, 2018
Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/update-patient-engagement-safety
Annual Perspective 2018
Background
Patient engagement has become a cornerstone of patient safety. A Patient Saf…
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hcup-us.ahrq.gov/reports/race/C18RECaseStudyReportforWEBfinal99.pdf
January 01, 2020 - Microsoft Word - C18RECaseStudyReportforWEBfinal99.docx
MAINTAIN AND EXPAND
THE HEALTHCARE COST AND UTILIZATION PROJECT (HCUP)
Contract No. HHSA-290-2006-00009-C
September 9, 2010
Prepared by:
Carrie Hanlon, MA and Susan Raetzman, MSPH
…
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - SPOTLIGHT CASE
Premature Closure: Was It Just Syncope?
Citation Text:
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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www.ahrq.gov/sites/default/files/2024-03/kennerly-report.pdf
January 01, 2024 - Final Progress Report: Improving the Safety of Primary Care by Measuring Adverse Events and Improvement
Improving the Safety of Primary Care by Measuring Adverse Events and Improvement
Principal Investigator:
Donald A. Kennerly, MD, PhD
Study Team:
Kenneth Bruce Bayley, PhD
Ashley Collinsworth, MPH
Teri Cowlin…
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www.ahrq.gov/patients-consumers/patient-involvement/patients-risk-of-falls.html
September 01, 2015 - New Tools Help Health Providers Reduce Patients' Risk of Falls
For older adults, falls are serious, no matter the setting. These falls can cause bone fractures, disability, and even death. Among people 75 and older, falls are far more likely to cause admissions into a long term care facility than for adults 10…
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psnet.ahrq.gov/node/838144/psn-pdf
September 21, 2022 - Eliminating Unintentionally Retained Surgical Items -
Special Report.
September 21, 2022
Saver C. AORN J. 2022;116(2):111-132.
https://psnet.ahrq.gov/issue/eliminating-unintentionally-retained-surgical-items-special-report
Retained surgical items (RSI) are regarded as “never events” but are a persistent cause of p…
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www.ahrq.gov/nursing-home/resources/module-11b-environmental-cleaning.html
May 01, 2022 - Module 11B—Environmental Cleaning and Disinfection—Nursing Home Infection Preventionist Training Course
Resource: Module 11B—Environmental Cleaning and Disinfection—Nursing Home Infection Preventionist Training Course
This module describes the role that environmental surfaces play in pathogen transmission an…
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www.ahrq.gov/nursing-home/resources/module-11c-water-management-program.html
May 01, 2022 - Module 11C—Water Management Program—Nursing Home Infection Preventionist Training Course
Resource: Module 11C—Water Management Program—Nursing Home Infection Preventionist Training Course
This module discusses the importance of a water management program in the prevention of the transmission of waterborne pa…
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www.ahrq.gov/nursing-home/resources/module-14-antibiotic-stewardship.html
April 01, 2022 - Module 14—Antibiotic Stewardship in Nursing Homes—Nursing Home Infection Preventionist Training Course
Resource: Module 14—Antibiotic Stewardship in Nursing Homes—Nursing Home Infection Preventionist Training Course
This module discusses the importance of antibiotic stewardship and identifies strategies to …
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www.ahrq.gov/nursing-home/resources/cms-targeted-training.html
May 01, 2022 - Centers for Medicare & Medicaid Services Targeted COVID-19 Training for Frontline Nursing Home Staff and Management
Resource: Centers for Medicare & Medicaid Services Targeted COVID-19 Training for Frontline Nursing Home Staff and Management
These self-paced, scenario based modules are intended to provide ad…
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www.ahrq.gov/hai/tools/enhanced-recovery/implementing/presentations.html
June 01, 2023 - Presentations on the ISCR Evidence
Use the presentations and facilitator guides in this section to gain buy-in from stakeholders. The presentations explain pathway components, techniques to implement them, evidence-based recommendations, and in some cases caveats for specific patient populations.
Oral Antib…
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www.ahrq.gov/nursing-home/resources/icar-facilitator-guide.html
April 01, 2022 - Nursing Home COVID-19 Infection Control Assessment & Response (ICAR) Tool Facilitator Guide
Resource: Nursing Home COVID-19 Infection Control Assessment & Response (ICAR) Tool Facilitator Guide
This updated infection control assessment and response tool is a longer but more comprehensive assessment of infec…
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psnet.ahrq.gov/node/34798/psn-pdf
June 23, 2015 - Costs of medical injuries in Utah and Colorado.
June 23, 2015
Thomas EJ; Studdert DM; Newhouse JP; Zbar BI; Howard KM; Williams EJ; Brennan TA
https://psnet.ahrq.gov/issue/costs-medical-injuries-utah-and-colorado
This study analyzed more than 450 adverse events from a representative hospital sample in order to
est…
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psnet.ahrq.gov/node/40486/psn-pdf
June 01, 2011 - Process changes to increase compliance with the
Universal Protocol for bedside procedures.
June 1, 2011
Barsuk JH, Brake H, Caprio T, et al. Process changes to increase compliance with the universal protocol
for bedside procedures. Arch Intern Med. 2011;171(10):947-9. doi:10.1001/archinternmed.2011.202.
https://ps…
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psnet.ahrq.gov/node/853445/psn-pdf
December 15, 2022 - Jake Tapper shares harrowing story of daughter's near-
fatal misdiagnosis.
December 15, 2022
CNN. December 15, 2022.
https://psnet.ahrq.gov/issue/jake-tapper-shares-harrowing-story-daughters-near-fatal-misdiagnosis
Diagnostic errors are a recognized cause of preventable patient harm. This video highlights a teen’…
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psnet.ahrq.gov/node/47817/psn-pdf
February 27, 2019 - FactFinders.
February 27, 2019
SIS Patient Safety Committee. Spine Intervention Society.
https://psnet.ahrq.gov/issue/factfinders
This resource provides newsletters that target concerns associated with spinal pain interventions and offers
safety strategies. The collection focuses on three primary areas: procedural…
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psnet.ahrq.gov/node/39964/psn-pdf
January 04, 2011 - Fatal consequences of a simple mistake: how can a
patient be saved from inadvertent intrathecal vincristine?
January 4, 2011
Reddy K, Brown B, Nanda A. Fatal consequences of a simple mistake: how can a patient be saved from
inadvertent intrathecal vincristine? Clin Neurol Neurosurg. 2011;113(1):68-71.
doi:10.1016/…
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psnet.ahrq.gov/node/42981/psn-pdf
March 19, 2014 - Recognizing and managing errors of cognitive
underspecification.
March 19, 2014
Duthie EA. Recognizing and managing errors of cognitive underspecification. J Patient Saf. 2014;10(1):1-5.
doi:10.1097/PTS.0b013e3182a5f6e1.
https://psnet.ahrq.gov/issue/recognizing-and-managing-errors-cognitive-underspecification
Inc…
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psnet.ahrq.gov/node/46469/psn-pdf
October 25, 2017 - RxAwareness.
October 25, 2017
Centers for Disease Control and Prevention; CDC.
https://psnet.ahrq.gov/issue/rxawareness
The opioid crisis is a persisting patient safety problem. One approach to prevent misuse of opioids is to
raise awareness of the addictive nature of the medication. This national campaign enlists…