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psnet.ahrq.gov/node/849605/psn-pdf
May 31, 2023 - Identification of patient safety threats in a post-intensive
care clinic.
May 31, 2023
Karlic KJ, Valley TS, Cagino LM, et al. Identification of patient safety threats in a post-intensive care clinic.
Am J Med Qual. 2023;38(3):117-121. doi:10.1097/jmq.0000000000000118.
https://psnet.ahrq.gov/issue/identification-p…
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psnet.ahrq.gov/node/40365/psn-pdf
February 12, 2014 - Strategies for learning from failure.
February 12, 2014
Edmondson A. Strategies of learning from failure. Harv Bus Rev. 2011;89(4):48-55, 137.
https://psnet.ahrq.gov/issue/strategies-learning-failure
Failures are inevitable in any industry, especially in one as complex as health care. The ability to learn from
fai…
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psnet.ahrq.gov/node/47558/psn-pdf
November 14, 2018 - What we can do about maternal mortality—and how to do
it quickly.
November 14, 2018
Mann S, Hollier LM, McKay K, et al. What We Can Do about Maternal Mortality - And How to Do It Quickly.
New Engl J Med. 2018;379(18):1689-1691. doi:10.1056/NEJMp1810649.
https://psnet.ahrq.gov/issue/what-we-can-do-about-maternal-mo…
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psnet.ahrq.gov/node/34673/psn-pdf
December 23, 2008 - Relationship between medication errors and adverse drug
events.
December 23, 2008
Bates DW, Boyle DL, Vliet MBV, et al. Relationship between medication errors and adverse drug events. J
Gen Intern Med. 1995;10(4):199-205.
https://psnet.ahrq.gov/issue/relationship-between-medication-errors-and-adverse-drug-events
…
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psnet.ahrq.gov/node/864380/psn-pdf
March 13, 2024 - Stepped-wedge cluster RCT to assess the effects of an
electronic medication system on medication
administration errors.
March 13, 2024
Westbrook JI, Li L, Woods AL, et al. Stepped-wedge cluster RCT to assess the effects of an electronic
medication system on medication administration errors. Stud Health Technol Inf…
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digital.ahrq.gov/sites/default/files/docs/page/ahrq-dhr-2022-year-in-review.pdf
January 01, 2022 - To
reduce VTE events, patients need preventive care, but guidelines for
providing preventive VTE care … Preventive Services
Task Force (USPSTF).
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psnet.ahrq.gov/web-mm/mistaken-identity
December 18, 2014 - Mistaken Identity
Citation Text:
Hall LW. Mistaken Identity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-alternatives-notes.docx
April 01, 2022 - Central Venous Catheter Indications and Alternatives Facilitator Notes
CAUTI Module:
Indwelling Urinary Catheter Alternatives
Facilitator Guide
Slide Number and Image
This module, titled “Indwelling Urinary Catheter Alternatives,” is part of the Agency for Healthcare Research and Quality’s Safety Program for in…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/infectious-complications-090914.pptx
January 01, 2014 - Slide 1
Infectious Complications Related to the Catheter Other than CAUTI
1
Mohamad Fakih, MD, MPH
Medical Director, Infection Prevention and Control
St. John Hospital and Medical Center
Professor of Medicine
Wayne State University School of Medicine
Detroit, MI
Nasia Safdar, MD, PhD
Associate Professor, Infectious…
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psnet.ahrq.gov/node/49554/psn-pdf
January 01, 2008 - Chemotherapy Extravasation
January 1, 2008
Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/chemotherapy-extravasation
The Case
A 73-year-old woman with no past medical history was diagnosed with stage IIIA breast cancer. She and
her oncologist decided to begin sys…
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psnet.ahrq.gov/node/33722/psn-pdf
December 01, 2011 - In Conversation With… Ann L. Hendrich, RN, PhD
December 1, 2011
In Conversation With… Ann L. Hendrich, RN, PhD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
Editor's note: Ann L. Hendrich, RN, PhD, is Vice President of Clinical Excellence Operations and
Executive Di…
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psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
June 29, 2020 - Annual Perspective
Pharmacist Role in Patient Safety
February 21, 2020
View more articles from the same authors.
Citation Text:
Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/perspective/conversation-cheryl-jones-about-addressing-workplace-violence-and-creating-safer
October 31, 2023 - Workplace violence in healthcare settings: the risk factors, implications and collaborative preventive
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psnet.ahrq.gov/node/33647/psn-pdf
March 01, 2007 - The Role of the Patient in Improving Patient Safety
March 1, 2007
Gibson R. The Role of the Patient in Improving Patient Safety. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
Perspective
Patients have three roles in improving patient safety: helping to ensure thei…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/prevent/leg-bags-faqs.html
July 01, 2017 - Frequently Asked Questions About the Use of and Care for Leg Bags in the Long-Term Care Setting
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Disclaimer: Answers to the following frequently asked questions (FAQs) are based on consensus of experts from a national project team of clinical facu…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/155-performing-premortem-project-assessment.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
Mini Presentation:
Performing a Premortem Project Assessment
ICU & Non-ICU
Slide Title and Commentary
Slide Number and Slide
Mini Presentation: Performing a Premortem Project Assessment
SAY:
Welcome to this mini presentation on why and how to use a Premortem Project Assessm…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/suicidal-thoughts-young-people-exe-sum.pdf
April 01, 2025 - Management of Suicidal Thoughts and Behaviors in Youth: A Systematic Review
Systematic Review
Management of Suicidal Thoughts and
Behaviors in Youth: A Systematic Review
Executive Summary
Main Points
• The current body of evidence is derived primarily from racially and ethnically
diverse f…
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psnet.ahrq.gov/node/45521/psn-pdf
December 21, 2016 - The effectiveness and risks of long-term opioid therapy
for chronic pain: a systematic review for a National
Institutes of Health Pathways to Prevention Workshop.
December 21, 2016
Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic
pain: a systematic review for…
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psnet.ahrq.gov/node/39216/psn-pdf
January 13, 2010 - How valid is the ICD-9-CM based AHRQ Patient Safety
Indicator for postoperative venous thromboembolism?
January 13, 2010
White RH, Sadeghi B, Tancredi DJ, et al. How Valid is the ICD-9-CM Based AHRQ Patient Safety Indicator
for Postoperative Venous Thromboembolism? Med Care. 2009;47(12):1237-1243.
doi:10.1097/mlr.…
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psnet.ahrq.gov/node/45577/psn-pdf
February 08, 2017 - EHR-related medication errors in two ICUs.
February 8, 2017
Carayon P, Du S, Brown RL, et al. EHR-related medication errors in two ICUs. J Healthc Risk Manag.
2017;36(3):6-15. doi:10.1002/jhrm.21259.
https://psnet.ahrq.gov/issue/ehr-related-medication-errors-two-icus
Despite the demonstrated success of technology …