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psnet.ahrq.gov/issue/guide-reducing-unintended-consequences-electronic-health-records
May 25, 2016 - Book/Report
Guide to Reducing Unintended Consequences of Electronic Health Records.
Citation Text:
Guide to Reducing Unintended Consequences of Electronic Health Records. Jones SS, Koppel R, Ridgely MS, Palen TE, Wu S, Harrison MI. Rockville, MD: Agency for Healthcare Research and …
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psnet.ahrq.gov/issue/one-hospitals-initiatives-encourage-safe-opioid-use
October 19, 2022 - Commentary
One hospital's initiatives to encourage safe opioid use.
Citation Text:
Surprise JK, Simpson MH. One Hospital's Initiatives to Encourage Safe Opioid Use. J Infus Nurs. 2015;38(4):278-83. doi:10.1097/NAN.0000000000000110.
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psnet.ahrq.gov/issue/fall-risk-and-prevention-agreement-engaging-patients-and-families-partnership-patient-safety
November 13, 2024 - Commentary
Fall risk and prevention agreement: engaging patients and families with a partnership for patient safety.
Citation Text:
Vonnes C, Wolf D. Fall risk and prevention agreement: engaging patients and families with a partnership for patient safety. BMJ Open Qual. 2017;6(2):e000038…
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www.ahrq.gov/news/newsroom/case-studies/201511.html
May 01, 2015 - St. Joseph’s Hospital Improves Patient Safety Using AHRQ Tools
Search All Impact Case Studies
May 2015
St. Joseph's Hospital, a 72-bed facility in Breese, Illinois, has improved care and increased satisfaction among patients by using three evidence-based resources from AHRQ:
The Hospital Consumer Asses…
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psnet.ahrq.gov/issue/cms-proposal-suppress-hospital-safety-data-angers-advocates-agency-says-covid-disruptions
June 15, 2022 - Newspaper/Magazine Article
CMS proposal to suppress hospital safety data angers advocates — agency says COVID disruptions, staff shortages hamper ability to fairly score poor performers.
Citation Text:
CMS proposal to suppress hospital safety data angers advocates — agency says COVID dis…
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psnet.ahrq.gov/issue/view-world-through-different-lens-shadowing-another-provider
January 22, 2017 - Commentary
View the world through a different lens: shadowing another provider.
Citation Text:
Thompson DA, Holzmueller CG, Lubomski LH, et al. View the world through a different lens: shadowing another provider. Jt Comm J Qual Patient Saf. 2008;34(10):614-8, 561.
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psnet.ahrq.gov/issue/partnership-patients
October 30, 2019 - Government Resource
Partnership for Patients.
Citation Text:
Partnership for Patients. Washington, DC: US Department of Health and Human Services.
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psnet.ahrq.gov/issue/action-planning-tool-ahrq-surveys-patient-safety-culture
February 12, 2019 - Toolkit
Action Planning Tool for the AHRQ Surveys on Patient Safety Culture.
Citation Text:
Action Planning Tool for the AHRQ Surveys on Patient Safety Culture. Yount N, Edelman S, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication …
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psnet.ahrq.gov/issue/critical-conversations-call-nonprocedural-time-out
February 18, 2011 - Commentary
Critical conversations: a call for a nonprocedural "time out."
Citation Text:
Sehgal NL, Fox M, Sharpe B, et al. Critical conversations: a call for a nonprocedural "time out". J Hosp Med. 2011;6(4):225-30. doi:10.1002/jhm.853.
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psnet.ahrq.gov/issue/national-healthcare-quality-and-disparities-report-chartbook-patient-safety-0
May 02, 2017 - Book/Report
National Healthcare Quality and Disparities Report Chartbook on Patient Safety.
Citation Text:
National Healthcare Quality and Disparities Report Chartbook on Patient Safety. Rockville, MD: Agency for Healthcare Research and Quality; March 2024. AHRQ Pub. No. 23-0046.
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psnet.ahrq.gov/issue/real-malady-marcel-proust-and-what-it-reveals-about-diagnostic-errors-medicine
September 27, 2022 - Commentary
The real malady of Marcel Proust and what it reveals about diagnostic errors in medicine.
Citation Text:
Douglas Y. The real malady of Marcel Proust and what it reveals about diagnostic errors in medicine. Med Hypotheses. 2016;90:14-8. doi:10.1016/j.mehy.2016.02.024.
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hcup-us.ahrq.gov/db/vars/key_nrd/nrdnote.jsp
August 01, 2015 - Healthcare Cost and Utilization Project (HCUP) NRD Notes
An official website of the Department of Health & Human Services
Search All AHRQ Websites
Careers
Contact Us
Espanol
FAQs…
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psnet.ahrq.gov/issue/iv-push-medications-survey-results-part-1-and-part-2
December 12, 2018 - Newspaper/Magazine Article
IV push medications survey results—part 1 and part 2.
Citation Text:
IV push medications survey results—part 1 and part 2. ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
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psnet.ahrq.gov/perspective/quality-and-safety-challenges-critical-care-preventing-and-treating-delirium-intensive
December 01, 2012 - June 14, 2017
Moving beyond readmission penalties: creating an ideal process to improve … January 5, 2011
Understanding patient-centred readmission factors: a multi-site, mixed-methods
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/sustain-facilitator-guide.pdf
November 01, 2019 - Sustaining Stewardship Activities Acute Care
AHRQ Safety Program for Improving
Antibiotic Use
1
AHRQ Pub. No. 17(20)-0028-EF
November 2019
Sustaining Stewardship Activities
Acute Care
Slide Title and Commentary Slide Number and Slide
Sustaining Stewardship Activities
Acute Care
SAY: …
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-IV-surgical-report-cards.pdf
July 01, 2023 - The ACA established the Hospital Readmission Reduction
Program which started a process to reduce hospital
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/thromboembolism-update_research-protocol.pdf
February 17, 2016 - leading to transfusion
§ Major bleeding leading to reoperation
§ Major bleeding leading to readmission …
o As defined by authors
o Fatal bleeding
o Resulting in transfusion, reoperation, or readmission …
o Resulting in reoperation
o Resulting in readmission
o Surgical site / joint bleeding
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psnet.ahrq.gov/node/73515/psn-pdf
August 01, 2022 - MOQI sought to improve transitional care
between hospitals and the nursing homes to prevent hospital readmission
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/ssi/ssiapu.pptx
September 18, 2011 - Cx_Site_Matchinteger
for example culture site hip for hip
operation
Re_Admitinteger
readmission on postop … day ___;
null if no readmission
PostOp_AbxInteger
Whether an antibiotic was given
postop day 3-30
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www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/redtool5.html
March 01, 2025 - families for discharge from the hospital, improve patient and family satisfaction, and decrease hospital readmission … We got her a commode and averted a readmission.”