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9181. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.251_slideshow.ppt
      October 01, 2011 - Spotlight Case [MONTH] 2003 Spotlight Case Mobility Lost in the ICU * * Source and Credits This presentation is based on the October 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jim Smith, PT, DPT, MA; Associate Professor of Physical …

9182. Responding to Patient Safety Events | PSNet
      psnet.ahrq.gov/primer/responding-patient-safety-events
      October 18, 2023 - Responding to Patient Safety Events Citation Text: Shaikh U. Responding to Patient Safety Events. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…

9183. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45705/psn-pdf
      January 23, 2017 - ASPEN Safe Practices for Enteral Nutrition Therapy. January 23, 2017 Boullata JI, Carrera AL, Harvey L, et al. ASPEN Safe Practices for Enteral Nutrition Therapy. JPEN J Parenter Enteral Nutr. 2017;41(1):15-103. doi:10.1177/0148607116673053. https://psnet.ahrq.gov/issue/aspen-safe-practices-enteral-nutrition-therap…

9184. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43403/psn-pdf
      August 06, 2014 - Strategies to enhance adoption of ventilator-associated pneumonia prevention interventions: a systematic literature review. August 6, 2014 Goutier JM, Holzmueller CG, Edwards KC, et al. Strategies to enhance adoption of ventilator-associated pneumonia prevention interventions: a systematic literature review. Infec…

9185. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42645/psn-pdf
      October 09, 2013 - Eliminating CAUTI: Interim Data Report: A National Patient Safety Imperative. October 9, 2013 Rockville, MD: Agency for Healthcare Research and Quality; July 2013. AHRQ Publication No. 13-0071- EF. https://psnet.ahrq.gov/issue/eliminating-cauti-interim-data-report-national-patient-safety-imperative This report pr…

9186. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72849/psn-pdf
      March 17, 2021 - There's no place like home--integrating a pharmacist into the hospital-in-home model. March 17, 2021 Emonds EE, Pietruszka BL, Hawley CE, et al. There’s no place like home—integrating a pharmacist into the hospital-in-home model. J Am Pharm Assoc (2003). 2021;61(3):e143-e151. doi:10.1016/j.japh.2021.01.003. https…

9187. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44170/psn-pdf
      May 29, 2023 - Ambulatory Surgery Center Survey on Patient Safety Culture. May 29, 2023 Rockville, MD: Agency for Healthcare Research and Quality; October 2020. https://psnet.ahrq.gov/issue/ambulatory-surgery-center-survey-patient-safety-culture Ambulatory surgery centers (ASCs) are increasingly being used to provide surgical ca…

9188. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60647/psn-pdf
      July 01, 2020 - Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups. July 1, 2020 Public Health England. London, UK: Crown Copyright; 2020. https://psnet.ahrq.gov/issue/beyond-data-understanding-impact-covid-19-bame-groups The COVID-19 pandemic has revealed weaknesses in health care systems worldwide that have af…

9189. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846164/psn-pdf
      March 15, 2023 - Crowding in the Emergency Department: Challenges for the Care of Children. March 15, 2023 Gross TK, Lane NE, Timm NL, et al. Crowding in the Emergency Department: Challenges for the Care of Children. Pediatrics. 2023;151(3):e2022060971-e2022060972. doi:10.1542/peds.2022-060971. https://psnet.ahrq.gov/issue/crowdin…

9190. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44794/psn-pdf
      May 21, 2019 - Medical Device Use Error: Root Cause Analysis. May 21, 2019 Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790. https://psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis Applying human factors engineering to examine mistakes associated with medical device use can lead …

9191. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852286/psn-pdf
      August 09, 2023 - Guidelines on Human Factors in Critical Situations 2023. August 9, 2023 Bijok B, Jaulin F, Picard J, et al. Guidelines on human factors in critical situations 2023. Anaesth Crit Care Pain Med. 2023;42(4):101262. doi:10.1016/j.accpm.2023.101262. https://psnet.ahrq.gov/issue/guidelines-human-factors-critical-situatio…

9192. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73075/psn-pdf
      March 24, 2021 - Analysis of transdermal medication patch errors uncovers a “patchwork” of safety challenges. March 24, 2021 ISMP Medication Safety Alert! Acute Care. March 11, 2021;26(5):1-6. https://psnet.ahrq.gov/issue/analysis-transdermal-medication-patch-errors-uncovers-patchwork-safety- challenges Skin patches are a conveni…

9193. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34749/psn-pdf
      January 09, 2017 - Patient Safety and the "Just Culture": A Primer for Health Care Executives. January 9, 2017 Marx DA. Patient Safety And The "Just Culture": A Primer For Health Care Executives. New York, NY: Trustees of Columbia University; 2001. https://psnet.ahrq.gov/issue/patient-safety-and-just-culture-primer-health-care-execu…

9194. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867632/psn-pdf
      February 26, 2025 - Instruments for patient safety assessment: a scoping review. February 26, 2025 Nunes E, Sirtoli F, Lima E, et al. Instruments for patient safety assessment: a scoping review. Healthcare. 2024;12(20):2075. doi:10.3390/healthcare12202075. https://psnet.ahrq.gov/issue/instruments-patient-safety-assessment-scoping-rev…

9195. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34715/psn-pdf
      February 18, 2011 - Continuous improvement as an ideal in health care. February 18, 2011 Berwick D. Continuous improvement as an ideal in health care. New Engl J Med. 1989;320(1):53-56. https://psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care Two approaches to improving quality in health care are illustrated in this artic…

9196. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43979/psn-pdf
      April 29, 2015 - The Report of the Morecambe Bay Investigation. April 29, 2015 Kirkup B. London, UK: The Stationery Office; 2015. ISBN: 9780108561306. https://psnet.ahrq.gov/issue/report-morecambe-bay-investigation Sharing information about large-scale investigations into failures can provide insights on factors that contribute to…

9197. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47514/psn-pdf
      October 31, 2018 - Making Hospitals Safe for People With Diabetes. October 31, 2018 Watts E, Rayman G. Diabetes UK. London, UK; 2018. https://psnet.ahrq.gov/issue/making-hospitals-safe-people-diabetes Chronic disease management can add complexity to inpatient care regimens. Researchers worked with patients, system leaders, and clini…

9198. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45164/psn-pdf
      May 25, 2016 - Eliminating Harm Checklists: Reduce All-Cause, Preventable Harm. May 25, 2016 Chicago, IL: American Hospital Association, Health Research & Educational Trust; 2016. https://psnet.ahrq.gov/issue/eliminating-harm-checklists-reduce-all-cause-preventable-harm Checklists are a recommended method to reduce omissions in …

9199. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46621/psn-pdf
      November 22, 2017 - Patient involvement for improved patient safety: a qualitative study of nurses' perceptions and experiences. November 22, 2017 Skagerström J, Ericsson C, Nilsen P, et al. Patient involvement for improved patient safety: A qualitative study of nurses' perceptions and experiences. Nurs Open. 2017;4(4):230-239. doi:10…

9200. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50554/psn-pdf
      October 16, 2019 - Adverse events in the operating room: definitions, prevalence, and characteristics. A systematic review. October 16, 2019 Jung JJ, Elfassy J, Jüni P, et al. Adverse Events in the Operating Room: Definitions, Prevalence, and Characteristics. A Systematic Review. World J Surg. 2019;43(10):2379-2392. doi:10.1007/s0026…