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130-Ss-Swiss-Cheese-Fg (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docxApril 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI Learning From Defects: Applying the “Swiss cheese model” of System Failure Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries Slide Title and Commentary Slide Number and Slide Learning From Defects: Applying the “Swiss C… -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pressureinjury-msmt_slides.pptxJune 02, 2025 - How To Measure Pressure Injury Rates and Prevention Practices How To Measure Pressure Injury Rates and Prevention Practices ADD Hospital Name Here Module 5 1 Basic Quality Improvement Principle If you can’t measure it, you can’t improve it. 2 2 Quality Improvement Principle Pressure injury rates and preven…
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www.ahrq.gov/hai/cusp/toolkit/content-calls/org-embrace-slides/slides.htmlJune 01, 2013 - Organizational Embrace of CUSP to Improve Patient Safety (Slide Presentation) On the CUSP: Stop BSI This PowerPoint slide presentation was shown on March 20, 2012. Contents Slide 1. The Organizational Embrace of CUSP to Improve Patient Safety Slide 2. Objectives Slide 3. Speakers Slide 4. Holy Cro…
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www.ahrq.gov/hai/cusp/modules/implement/teamwork.htmlDecember 01, 2012 - Implement Teamwork and Communication CUSP Toolkit The Implement Teamwork and Communication module of the CUSP Toolkit will help you to identify barriers to communication. Contents Slide 1. Cover Slide Slide 2. Learning Objectives Slide 3. Basic Components and Process of Communication 2 Slide 4. Four…
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psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decisionOctober 30, 2024 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL February 9, 2021 …
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www.ahrq.gov/patient-safety/quality-measures/qsrs/sampling-design.htmlSeptember 01, 2025 - QSRS 2020–2024 Sampling Design and Weighting Methodology 1. Introduction The Quality and Safety Review System (QSRS) was designed to identify the occurrence of specified adverse events to gain a better understanding of patient safety in the hospital setting. 1 In collaboration with the Centers for Medicare & M…
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Pccds-Ln-Opioid-Action-Plan-2019 (pdf file)
digital.ahrq.gov/sites/default/files/docs/citation/pccds-ln-opioid-action-plan-2019.pdfJanuary 01, 2019 - 1 A Stakeholder-driven Action Plan for Improving Pain Management, Opioid Use, and Opioid Use Disorder Treatment Through Patient-Centered Clinical Decision Support Jerome A. Osheroff, MD Barry H. Blumenfeld, MD, MS Joshua E. Richardson, PhD, MS, MLIS Beth Lasater, MSPH … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836791/psn-pdfAugust 21, 2024 - TeamSTEPPS for Diagnosis Improvement. August 21, 2024 TeamSTEPPS for Diagnosis Improvement. https://psnet.ahrq.gov/issue/teamstepps-diagnosis-improvement The recognition of diagnosis as a team activity is energizing new diagnostic process initiatives. Building on the established TeamSTEPPS® principles, this new Te… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40646/psn-pdfJuly 27, 2011 - Engineering a Learning Healthcare System: A Look at the Future: Workshop Summary. July 27, 2011 Grossmann C, Goolsby WA, Olsen L, McGinnis JM; Institute of Medicine and National Academy of Engineering. Washington, DC: The National Academies Press; 2011. ISBN: 9780309120647. https://psnet.ahrq.gov/issue/engineering… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45932/psn-pdfMay 18, 2017 - Polypharmacy. May 18, 2017 Zagaria MAE, ed. Clin Geriatr Med. 2017;33:153-292. https://psnet.ahrq.gov/issue/polypharmacy Older patients are likely to be prescribed multiple medications, which can increase risks. Articles in this special issue explore polypharmacy in a variety of care settings and provide tactics f… -
digital.ahrq.gov/ahrq-funded-projects/impact-office-based-e-prescribing-prescribing-processes-and-outcomes/citation-1January 01, 2023 - Prior authorization for biologic disease-modifying antirheumatic drugs: a description of US Medicaid programs. Citation Fischer MA, Polinski JM, Servi AD, et al. Prior authorization for biologic disease-modifying antirheumatic drugs: a description of US Medicaid programs. Arthritis Rheum 2008 Nov 15;5…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39175/psn-pdfDecember 16, 2009 - Impact of a standard medication chart on prescribing errors: a before-and-after audit. December 16, 2009 Coombes ID, Stowasser DA, Reid C, et al. Impact of a standard medication chart on prescribing errors: a before-and-after audit. Qual Saf Health Care. 2009;18(6):478-85. doi:10.1136/qshc.2007.025296. https://psn… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41506/psn-pdfOctober 12, 2012 - Preventable errors in organ transplantation: an emerging patient safety issue? October 12, 2012 Ison MG, Holl JL, Ladner D. Preventable errors in organ transplantation: an emerging patient safety issue? Am J Transplant. 2012;12(9):2307-12. doi:10.1111/j.1600-6143.2012.04139.x. https://psnet.ahrq.gov/issue/preventa… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50763/psn-pdfDecember 18, 2019 - Their kids died on the psych ward. They were far from alone, a Times investigation found. December 18, 2019 Karlamangla S. Los Angeles Times. December 1, 2019. https://psnet.ahrq.gov/issue/their-kids-died-psych-ward-they-were-far-alone-times-investigation-found Patient suicide is considered a sentinel event. This … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44441/psn-pdfAugust 26, 2015 - Preventing Falls With Injury. August 26, 2015 Joint Commission Center for Transforming Healthcare; TST. https://psnet.ahrq.gov/issue/preventing-falls-injury Patient falls are preventable and can be addressed through quality and safety strategies. This toolkit provides a process to help health care organizations de… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47966/psn-pdfMay 29, 2019 - Patient Safety Essentials Toolkit. May 29, 2019 Boston, MA: Institute for Healthcare Improvement; 2019. https://psnet.ahrq.gov/issue/patient-safety-essentials-toolkit This toolkit provides access to nine key tools to help organizations improve teamwork, incident analysis, and communication as well as templates to … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41064/psn-pdfMarch 02, 2012 - Blending evidence and innovation: improving intershift handoffs in a multihospital setting. March 2, 2012 Thomas L, Donohue-Porter P. Blending evidence and innovation: improving intershift handoffs in a multihospital setting. J Nurs Care Qual. 2012;27(2):116-24. doi:10.1097/NCQ.0b013e318241cb3b. https://psnet.ahrq… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40066/psn-pdfJanuary 01, 2011 - Communication errors in dispatch of air medical transport. December 8, 2010 Vilensky D, MacDonald RD. Communication errors in dispatch of air medical transport. Prehosp Emerg Care. 2011;15(1):39-43. doi:10.3109/10903127.2011.519817. https://psnet.ahrq.gov/issue/communication-errors-dispatch-air-medical-transport … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37350/psn-pdfJanuary 05, 2012 - How safe is my intensive care unit? Methods for monitoring and measurement. January 5, 2012 Berenholtz SM, Pustavoitau A, Schwartz SJ, et al. How safe is my intensive care unit? Methods for monitoring and measurement. Curr Opin Crit Care. 2007;13(6):703-8. https://psnet.ahrq.gov/issue/how-safe-my-intensive-care-un… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35010/psn-pdfMay 18, 2005 - Hospital-error oversight called lax: state takes too long to investigate mistakes, patient advocates say. May 18, 2005 Galloway A. Seattle Post-Intelligencer. May 4, 2005. https://psnet.ahrq.gov/issue/hospital-error-oversight-called-lax-state-takes-too-long-investigate-mistakes- patient This article explores…
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