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psnet.ahrq.gov/node/33561/psn-pdf
September 15, 2024 - Background
The term "Never Event" was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality … multiple
times, and now consists of 29 "serious reportable events" grouped into 7 categories:
National Quality … than as intended
https://psnet.ahrq.gov/primer/never-events
https://psnet.ahrq.gov/issue/national-quality-forum … Events are also being publicly reported, with the goal of increasing accountability and improving the
quality … National Quality Forum. List of Serious Reportable Events.
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psnet.ahrq.gov/node/866618/psn-pdf
December 31, 2024 - This activity is jointly provided by the Agency
for Healthcare Research and Quality (AHRQ) PSNet. … hyperkalemia, or poisoning from salicylates or tricyclic
antidepressants.15,16
System Optimization and Quality … EHR systems should incorporate easily seen indicators and notifications when hemolysis is
detected. … Blood sample quality. Diagnosis (Berl). 2019;6(1):25-31. [
Free full text]
3. … project was funded under contract number 75Q80119C00004 from the Agency for Healthcare
Research and Quality
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psnet.ahrq.gov/issue/ahrq-webmm-morbidity-mortality-rounds-web
December 24, 2008 - Agency for Healthcare Research and Quality. … Linkedin
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July 26, 2010
Agency for Healthcare Research and Quality … Agency for Healthcare Research and Quality. … June 14, 2024
- December 14, 2025
Patient Safety Indicators Overview. … November 9, 2016
Quality and Patient Safety.
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psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
September 01, 2014 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … indicators that measure overuse is a vital step toward improvements on a national scale. … The urgent need to improve health care quality. … Developing quality measures to address overuse. JAMA. 2013;309:1897-1898.
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psnet.ahrq.gov/perspective/overuse-patient-safety-problem
September 01, 2014 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … indicators that measure overuse is a vital step toward improvements on a national scale. … The urgent need to improve health care quality. … Institute of Medicine National Roundtable on Health Care Quality. JAMA. 1998;280:1000-1005. … Developing quality measures to address overuse. JAMA. 2013;309:1897-1898.
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psnet.ahrq.gov/issue/do-junior-doctors-make-more-prescribing-errors-experienced-doctors-when-prescribing
February 22, 2023 - 2024
Annual Perspective
Improving Diagnostic Safety and Quality
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psnet.ahrq.gov/node/33562/psn-pdf
September 15, 2024 - https://psnet.ahrq.gov/issue/100000-lives-campaign-setting-goal-and-deadline-improving-health-care-quality
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psnet.ahrq.gov/primer/falls
October 27, 2021 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … found that falls occur at a rate of 3–5 per 1000 bed-days, and the Agency for Healthcare Research and Quality … One widely cited, high-quality randomized trial documented a significant reduction in falls among elderly … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services
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psnet.ahrq.gov/node/33574/psn-pdf
March 15, 2025 - Burnout and work
dissatisfaction, particularly among primary care physicians, may adversely affect the quality … https://psnet.ahrq.gov/issue/2008-update-consumers-views-patient-safety-and-quality-information
https … culture-safety
https://psnet.ahrq.gov/issue/working-conditions-primary-care-physician-reactions-and-care-quality … The Agency for Healthcare Research
and Quality is also leading efforts to improve ambulatory quality
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psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
March 01, 2018 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … The state has seen steeper declines in mortality and improvements in other indicators than other states … Again, we have validation that there is tremendous variation in the quality of the work environment … 'Care left undone' during nursing shifts: associations with workload and perceived quality of care.
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - differential, and assist clinicians to refine their selection of laboratory tests and imaging:
Pain location, quality … symptoms such as fever, nausea, vomiting, and diarrhea
Physical exam findings such as the location and quality … imaging has increased significantly over the last 20 years, driven largely by improved availability and quality
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psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
April 01, 2008 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … One clear source of the clinical dilemma is the lack of high-quality data to help guide clinicians. … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … October 7, 2015
Hospital quality and patient safety competencies: development, description
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psnet.ahrq.gov/node/40982/psn-pdf
March 23, 2012 - incidence-adverse-drug-events-and-potential-adverse-drug-events-implications-prevention
https://psnet.ahrq.gov/issue/preventing-medication-errors-quality-chasm-series … https://psnet.ahrq.gov/issue/use-specific-indicators-detect-warfarin-related-adverse-events
https://
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psnet.ahrq.gov/node/42652/psn-pdf
October 31, 2014 - The group synthesized 26 distinct safety indicators into a
score comprised equally of process measures … safety-numbers-development-leapfrogs-composite-patient-safety-score-us-hospitals
https://psnet.ahrq.gov/issue/accountability-measures-using-measurement-promote-quality-improvement
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psnet.ahrq.gov/issue/healthcare-associated-infections
January 10, 2018 - Same Author(s)
Five Years of Experience Using Front-line Ownership to Improve Healthcare Quality … March 9, 2016
Dissemination of Lean methods to improve Pap testing quality and patient … November 10, 2010
Quality and Safety Education for Nurses. … July 3, 2013
Validity of Patient Safety Indicators in the Veterans Health Administration
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psnet.ahrq.gov/node/47671/psn-pdf
January 01, 2019 - https://psnet.ahrq.gov/issue/racial-ethnic-and-socioeconomic-disparities-estimates-ahrq-patient-safety-indicators … racial-disparities-frequency-patient-safety-events-results-national-medicare-patient-safety
https://psnet.ahrq.gov/issue/national-healthcare-quality-and-disparities-report-chartbook-patient-safety
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psnet.ahrq.gov/issue/charting-course-launching-patient-centric-healthcare
December 19, 2018 - Same Author(s)
Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality … March 5, 2013
Health IT-Enabled Quality Measurement: Perspectives, Pathways, and Practical … Unintended consequences of health care reform: impact of changes in payor mix on patient safety indicators … April 1, 2024
National Healthcare Quality and Disparities Reports. … November 26, 2013
HealthGrades Quality Study: Fourth Annual Patient Safety in American
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psnet.ahrq.gov/issue/improvement-cymru
October 20, 2014 - The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020 … View More
Related Resources
Validity of 16 AHRQ Patient Safety Indicators … May 9, 2012
WebM&M Cases
The Safety and Quality of Long
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psnet.ahrq.gov/node/45744/psn-pdf
December 19, 2017 - hospital-characteristics-associated-penalties-centers-medicare-medicaid-services-hospital
https://psnet.ahrq.gov/issue/validity-agency-healthcare-research-and-quality-patient-safety-indicators-and-centers
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psnet.ahrq.gov/node/43745/psn-pdf
December 17, 2014 - longer length of stay, and higher cost) beyond the
standard Centers for Medicare and Medicaid Services indicators … complications (i.e., increased sensitivity), not all of
them can be attributed with certainty to the quality