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psnet.ahrq.gov/node/38454/psn-pdf
January 02, 2017 - Comparing process- and outcome-oriented approaches to
voluntary incident reporting in two hospitals.
January 2, 2017
Nuckols TK, Bell D, Paddock SM, et al. Comparing process- and outcome-oriented approaches to
voluntary incident reporting in two hospitals. Jt Comm J Qual Patient Saf. 2009;35(3):139-45.
https://psn…
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psnet.ahrq.gov/node/38675/psn-pdf
February 15, 2011 - Prescription errors and outcomes related to inconsistent
information transmitted through computerized order
entry: a prospective study.
February 15, 2011
Singh H, Mani S, Espadas D, et al. Prescription errors and outcomes related to inconsistent information
transmitted through computerized order entry: a prospecti…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/assessment.docx
May 01, 2017 - HRQ Safety Program for Perinatal Care: Labor and Delivery Unit Staff Safety Assessment
AHRQ Safety Program for Perinatal Care
Labor and Delivery Unit Staff Safety Assessment
Purpose: To tap into the knowledge and experiences of labor and delivery (L&D) providers and other clinical and nonclinical staff (e.g., healt…
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www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/finish.html
September 01, 2015 - Preventing CAUTI in the ICU Setting: Facilitator’s Guide
Finishing Up Strong
Previous Page
Table of Contents
Preventing CAUTI in the ICU Setting: Facilitator’s Guide
Introduction
Module 1: Overview
Module 2: Urinary Catheter Maintenance
Module 3: Conversations Around Device Necessity
Mod…
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www.ahrq.gov/cpi/about/otherwebsites/qualityindicators.ahrq.gov/qualityindicators.html
February 01, 2025 - AHRQuality Indicators™
Mission The Quality Indicators are measures of health care quality that use readily available hospital inpatient administrative data. AHRQ develops Quality Indicators to provide health care decisionmakers with tools to assess their data. Visit the AHRQuality Indicators™ Web site . Releva…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/sustainability.html
July 01, 2018 - Sustainability
Toolkit To Reduce CAUTI and Other HAIs in Long-Term Care Facilities
This section explains the importance of planning for sustainability from the beginning and provides an overview of factors to help achieve sustainable gains. Infection prevention strategies can only be sustained if they are emb…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/111-ss-cusp-lfd-worksheet-a3.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Investigating a Defect Worksheet
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion SurgeriesOwner: ____________________________
Date Defect Occurred: ________________
Date Investigation Initiated: ___________
Use the Learning From …
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/111-cusp-learning-from-defects-worksheet.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Investigating a Defect Worksheet
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion SurgeriesOwner: ____________________________
Date Defect Occurred: ________________
Date Investigation Initiated: ___________
Use the Learning From …
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/handouts/staff-iodophor.docx
March 01, 2022 - Nasal Iodophor
MRSA Carriers With Devices: Prevent Infections During the Hospital Stay STAFFSection 10-5
How To Apply Nasal 10% Povidone-Iodine (Iodophor)
AHRQ Pub. No. 20(22)-0036
March 2022
Apply nasal povidone-iodine antiseptic swabs twice daily for 5 days to all adult non-ICU patients with medical device…
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www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/mod3-slides.html
February 01, 2023 - Module 3: Conversations Around Device Necessity
Preventing CAUTI in the ICU Setting Slide Presentation
Slide 1
AHRQ Safety Program for Reducing CAUTI in Hospitals
Preventing CAUTI in the ICU Setting
Module 3: Conversations Around Device Necessity
AHRQ Pub No. 15-0073-4-EF
September 2015
Slide 2
…
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psnet.ahrq.gov/node/60246/psn-pdf
April 22, 2020 - The impact of surgical count technology on retained
surgical items rates in the Veterans Health
Administration.
April 22, 2020
Gunnar W, Soncrant C, Lynn MM, et al. The impact of surgical count technology on retained surgical items
rates in the Veterans Health Administration. J Patient Saf. 2020;16(4):255-258.
do…
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psnet.ahrq.gov/node/854831/psn-pdf
January 01, 2024 - Medication safety events after acute myocardial infarction
among veterans treated at VA versus non-VA hospitals.
October 25, 2023
Weeda ER, Ward R, Gebregziabher M, et al. Medication safety events after acute myocardial infarction
among veterans treated at VA versus non-VA hospitals. Med Care. 2024;62(2):72-78.
do…
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psnet.ahrq.gov/node/852274/psn-pdf
August 09, 2023 - Associations between self-reported healthcare disruption
due to COVID-19 and avoidable hospital admission:
evidence from seven linked longitudinal studies for
England.
August 9, 2023
Green MA, McKee M, Hamilton OKL, et al. Associations between self-reported healthcare disruption due to
covid-19 and avoidable hosp…
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psnet.ahrq.gov/node/37499/psn-pdf
January 10, 2017 - Medicare's decision to withhold payment for hospital
errors: the devil is in the details.
January 10, 2017
Wachter R, Foster NE, Dudley A. Medicare's decision to withhold payment for hospital errors: the devil is in
the det. Jt Comm J Qual Patient Saf. 2008;34(2):116-23.
https://psnet.ahrq.gov/issue/medicares-deci…
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psnet.ahrq.gov/node/35855/psn-pdf
October 25, 2013 - HealthGrades Quality Study: Third Annual Patient Safety
in American Hospitals Study.
October 25, 2013
Denver, CO: HealthGrades; 2006.
https://psnet.ahrq.gov/issue/healthgrades-quality-study-third-annual-patient-safety-american-hospitals-
study
This third annual report on the safety of hospitalized Medicare patien…
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psnet.ahrq.gov/node/45829/psn-pdf
June 27, 2018 - Learning from errors: analysis of medication order
voiding in CPOE systems.
June 27, 2018
Kannampallil TG, Abraham J, Solotskaya A, et al. Learning from errors: analysis of medication order
voiding in CPOE systems. J Am Med Inform Assoc. 2017;24(4):762-768. doi:10.1093/jamia/ocw187.
https://psnet.ahrq.gov/issue/le…
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psnet.ahrq.gov/node/43190/psn-pdf
September 04, 2015 - Pediatric obesity and safety in inpatient settings: a
systematic literature review.
September 4, 2015
Halvorson EE, Irby MB, Skelton JA. Pediatric obesity and safety in inpatient settings: a systematic literature
review. Clin Pediatr (Phila). 2014;53(10):975-87. doi:10.1177/0009922814533406.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/36308/psn-pdf
January 05, 2017 - A trigger tool to identify adverse events in the intensive
care unit.
January 5, 2017
Resar RK, Rozich JD, Simmonds T, et al. A Trigger Tool to Identify Adverse Events in the Intensive Care
Unit. The Joint Commission Journal on Quality and Patient Safety. 2016;32(10). doi:10.1016/s1553-
7250(06)32076-4.
https://…
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psnet.ahrq.gov/node/41898/psn-pdf
December 05, 2012 - Pharmacy dispensing of electronically discontinued
medications.
December 5, 2012
Allen AS, Sequist TD. Pharmacy dispensing of electronically discontinued medications. Ann Intern Med.
2012;157(10):700-705. doi:10.7326/0003-4819-157-10-201211200-00006.
https://psnet.ahrq.gov/issue/pharmacy-dispensing-electronically-…
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psnet.ahrq.gov/node/37776/psn-pdf
January 31, 2011 - Barcoded medication administration: a last line of
defense.
January 31, 2011
Cescon DW, Etchells E. Barcoded medication administration: a last line of defense. JAMA.
2008;299(18):2200-2. doi:10.1001/jama.299.18.2200.
https://psnet.ahrq.gov/issue/barcoded-medication-administration-last-line-defense
Barcoding techn…