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5521. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45012/psn-pdf
      September 28, 2016 - Nursing strategies to increase medication safety in inpatient settings. September 28, 2016 Bravo K, Cochran GL, Barrett R. Nursing Strategies to Increase Medication Safety in Inpatient Settings. J Nurs Care Qual. 2016;31(4):335-41. doi:10.1097/NCQ.0000000000000181. https://psnet.ahrq.gov/issue/nursing-strategies-i…

5522. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42525/psn-pdf
      November 20, 2013 - A Promise to Learn—a Commitment to Act: Improving the Safety of Patients in England. November 20, 2013 National Advisory Group on the Safety of Patients in England. London, England: Crown Publishing; August 2013. https://psnet.ahrq.gov/issue/promise-learn-commitment-act-improving-safety-patients-england An intern…

5523. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45590/psn-pdf
      August 02, 2017 - Improving Diagnostic Accuracy Project 2016–2017. August 2, 2017 Washington, DC: National Quality Forum; October 2016. https://psnet.ahrq.gov/issue/improving-diagnostic-accuracy-project-2016-2017 The Improving Diagnosis in Health Care report provided recommendations to help achieve safe, reliable diagnosis. This we…

5524. 67. For the Patient Willing To Quit (Continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide67.html
      October 01, 2014 - 67. For the Patient Willing To Quit (Continued) Treating Tobacco Use and Dependence: 2008 Update Text version of slide presentation. Strategy A4. Assist —Aid the patient in quitting (provide counseling and medication) (Continued) Provide intra-treatment social support. Provide a supportive clin…

5525. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73926/psn-pdf
      October 06, 2021 - Good for You, Good for Us, Good for Everybody. October 6, 2021 Ridge K. London, England: Crown Copyright; 2021. September 22, 2021. https://psnet.ahrq.gov/issue/good-you-good-us-good-everybody Overprescribing has attained prominence as a safety issue due to the current opioid epidemic, but it has long reduced medi…

5526. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43212/psn-pdf
      September 27, 2017 - Errors of omission: missed nursing care. September 27, 2017 Kalisch BJ, Xie B. Errors of Omission: Missed Nursing Care. West J Nurs Res. 2014;36(7):875-890. doi:10.1177/0193945914531859. https://psnet.ahrq.gov/issue/errors-omission-missed-nursing-care Nurse staffing ratios have been linked to patient safety issues…

5527. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40142/psn-pdf
      April 04, 2011 - Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. April 4, 2011 Zahiri HR, Stromberg J, Skupsky H, et al. Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. Surg Innov. 2011;18(1):55-60. doi:10.1177/1553350610389196. htt…

5528. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35219/psn-pdf
      June 12, 2013 - Learning how to learn: compliance with patient safety alerts in the NHS. June 12, 2013 Donaldson L. Chapter in: On the State of Public Health: Annual Report of the Chief Medical Officer. London, UK: Department of Health; 2004. https://psnet.ahrq.gov/issue/learning-how-learn-compliance-patient-safety-alerts-nhs Th…

5529. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33956/psn-pdf
      March 07, 2005 - The Report of the Manitoba Pediatric Cardiac Surgery Inquest: An Inquiry into Twelve Deaths at the Winnipeg Health Sciences Center in 1994. March 7, 2005 Inquest, Manitoba Pediatric Cardiac Surgery. Winnepeg, Manitoba: Provincial Court of Manitoba; 1999. ISBN 0771115164. https://psnet.ahrq.gov/issue/report-manito…

5530. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43795/psn-pdf
      December 17, 2014 - Systematic Systems Analysis: A Practical Approach to Patient Safety Reviews. December 17, 2014 Duchscherer C, Davies JM. Calgary, Alberta, Canada: Health Quality Council of Alberta; 2012. https://psnet.ahrq.gov/issue/systematic-systems-analysis-practical-approach-patient-safety-reviews Drawing from human factors a…

5531. Centers for Disease Control & Prevention (CDC) COVID-19 Vaccination Program Provider Requirements and Support | Agency for Healthcare Research and Quality
      www.ahrq.gov/nursing-home/resources/cdc-provider-requirements-support.html
      August 01, 2022 - Centers for Disease Control & Prevention (CDC) COVID-19 Vaccination Program Provider Requirements and Support Resource: Centers for Disease Control & Prevention (CDC)  COVID-19 Vaccination Program Provider Requirements and Support This page provides information about the Centers for Disease Control & Preve…

5532. Assessing TAKEheart | Agency for Healthcare Research and Quality
      www.ahrq.gov/takeheart/assessing/index.html
      August 01, 2023 - Assessing TAKEheart Through our assessment of TAKEheart, we learned many lessons that will help guide future work in this area. Our Evaluation Report Executive Summary describes the project activities, key findings, lessons learned, and recommendations for future similar efforts. Our Hybrid Cardiac Rehabilita…

5533. Risk Assessment and Management of Exposure of Healthcare Workers in the Context of COVID-19: Data Template | Agency for Healthcare Research and Quality
      www.ahrq.gov/nursing-home/resources/risk-assessment-management.html
      April 01, 2022 - Risk Assessment and Management of Exposure of Healthcare Workers in the Context of COVID-19: Data Template Resource: Risk Assessment and Management of Exposure of Healthcare Workers in the Context of COVID-19: Data Template ​This tool is intended for health care facilities that have either cared for or admit…

5534. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/845079/psn-pdf
      February 22, 2023 - Pump up the volume: how to prioritize events and analyze error data. February 22, 2023 ISMP Medication Safety Alert! Acute care edition. February 9, 2023;28(3):1-4. https://psnet.ahrq.gov/issue/pump-volume-how-prioritize-events-and-analyze-error-data Patient safety event reporting is an established component of a …

5535. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49693/psn-pdf
      October 01, 2013 - It's Sarah, Not Stephen! October 1, 2013 Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/its-sarah-not-stephen Case Objectives Define and distinguish the terms gender identity, gender expression, and gender variance. Delineate patient safety issues associated with transge…

5536. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. | PSNet
      psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
      February 21, 2020 - Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. Citation Text: Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. …

5537. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49568/psn-pdf
      September 01, 2008 - Failure to Latch September 1, 2008 Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/failure-latch The Case The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to breastfeeding exclusively for 6 months. However, early br…

5538. Layout 1 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/cancer-anemia_executive.pdf
      May 01, 2006 - Layout 1 Background Anemia (deficiency of red blood cells) occurs in 13-78 percent of patients undergoing treatment for solid tumors and 30-40 percent of patients treated for lymphoma. Tumor type, treatment regimen, and history of prior cancer therapy influence the risk and severity of anemia. For example, among pa…

5539. Hyponatremia Secondary to Home Parenteral Nutrition Error | PSNet
      psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
      May 27, 2020 - Hyponatremia Secondary to Home Parenteral Nutrition Error Citation Text: Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: …

5540. Diagnostic Safety Centers of Excellence | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/diagnostic-excellence-grants/index.html
      February 01, 2025 - Diagnostic Safety Centers of Excellence In fiscal year 2022, Congress authorized funding to support AHRQ's research to address failures in the diagnostic process, which may include the establishment of Research Centers of Diagnostic Excellence to develop systems, measures, and new technology solutions to improv…