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4341. Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. | PSNet
      psnet.ahrq.gov/issue/implementing-robust-process-improvement-program-neonatal-intensive-care-unit-reduce-harm
      March 23, 2022 - Study Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. Citation Text: Nether KG, Thomas EJ, Khan A, et al. Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. J Healthc Qual. 2022;44(1)…

4342. Checklists to reduce diagnostic error: a systematic review of the literature using a human factors framework. | PSNet
      psnet.ahrq.gov/issue/checklists-reduce-diagnostic-error-systematic-review-literature-using-human-factors-framework
      February 22, 2023 - Review Checklists to reduce diagnostic error: a systematic review of the literature using a human factors framework. Citation Text: Al-Khafaji J, Townshend RF, Townsend W, et al. Checklists to reduce diagnostic error: a systematic review of the literature using a human factors framework.…

4343. Task Force Issues Draft Recommendation Statement on Interventions to Prevent Falls in Older Adults (pdf file)
      www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/falls-prevention-older-adults-draft-rec-bulletin.pdf
      January 08, 2024 - Task Force Issues Draft Recommendation Statement on Interventions to Prevent Falls in Older Adults www.uspreventiveservicestaskforce.org 1 Task Force Issues Draft Recommendation Statement on Interventions to Prevent Falls in Older Adults Exercise can reduce the likelihood of falls in adults 65 and older; a…

4344. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
      January 01, 2004 - Salt Lake City, a computerized physician/provider order entry (CPOE) system with decision support reduced

4345. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/73848
      July 01, 2022 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Maternal Safety Curated Library Foundations Maternal Safety Marla Shauer, PhD(c), MSN, CNM; Amy Nichols, EdD, RN, CNS, CHSE, ANEF; Audrey Lyndon, RN, PhD, FAAN | January, 31 2024 Pregnancy, childbirth, and the postpartum year present a comp…

4346. Central Venous Catheter Insertion Bundle Facilitator Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-insertion-notes.docx
      April 01, 2022 - of evidence-based care, improved communication, appropriate use of equipment, minimized errors, and reduced

4347. 005-Ss-Preop-Chlorhexidine-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/005-ss-preop-chlorhexidine-fg.docx
      April 01, 2025 - In an unadjusted analysis, the risk of SSIs was reduced by 84 percent in the group that used the preoperative

4348. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61057/psn-pdf
      October 28, 2020 - Improving Diagnostic Quality and Safety/Reducing Diagnostic Error: Measurement Considerations. Final Report October 28, 2020 Washington DC; National Quality Forum: October 6, 2020. https://psnet.ahrq.gov/issue/improving-diagnostic-quality-and-safetyreducing-diagnostic-error- measurement-considerations With input…

4349. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50865/psn-pdf
      February 05, 2020 - Understanding principles of high reliability organizations through the eyes of VIONE: a clinical program to improve patient safety by deprescribing potentially inappropriate medications and reducing polypharmacy. February 5, 2020 Battar S, Dickerson KRW, Sedgwick C, et al. Understanding principles of high reliabil…

4350. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38572/psn-pdf
      April 22, 2009 - Development and validation of the SURgical PAtient Safety System (SURPASS) checklist. April 22, 2009 de Vries EN, Hollmann MW, Smorenburg SM, et al. Development and validation of the SURgical PAtient Safety System (SURPASS) checklist. Qual Saf Health Care. 2009;18(2):121-6. doi:10.1136/qshc.2008.027524. https://p…

4351. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44768/psn-pdf
      February 03, 2016 - Recommendations and low-technology safety solutions following neuromuscular blocking agent incidents. February 3, 2016 Graudins L, Downey G, Bui T, et al. Recommendations and Low-Technology Safety Solutions Following Neuromuscular Blocking Agent Incidents. Jt Comm J Qual Patient Saf. 2016;42(2):86-91. https://psne…

4352. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837200/psn-pdf
      May 25, 2022 - Analysis of readmissions in a mobile integrated health transitional care program using root cause analysis and common cause analysis. May 25, 2022 Buitrago I, Seidl KL, Gingold DB, et al. Analysis of readmissions in a mobile integrated health transitional care program using root cause analysis and common cause ana…

4353. Organizing Quality Measures To Reduce Information Overload | Agency for Healthcare Research and Quality
      www.ahrq.gov/talkingquality/translate/organize/index.html
      March 01, 2016 - Organizing Quality Measures To Reduce Information Overload As the number of available quality measures grows, report designers face the challenge of providing a great deal of information without overwhelming the user. In addition, individual users of the report may be interested in different measures, so they n…

4354. 021-Ss-Mrsa-Surveillance-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/021-ss-mrsa-surveillance-fg.docx
      April 01, 2025 - The study found that the use of contact precautions reduced MRSA transmission by 47 percent when it was

4355. Screening for Chlamydial Infection: An Evidence Update (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/REES__d2DxtDLhZCXQjpPW
      July 01, 2007 - concluded that screening and treating young women at increased risk for chlamydial infection significantly reduced

4356. Making Healthcare Safer III: Executive Summary | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/exe-summary.html
      March 01, 2020 - In the second Making Healthcare Safer report, team training was associated with reduced errors and safety … Simulation-based medical education curriculums were associated with decreased complication rates, fewer errors, reduced

4357. Preventing Medication-Related Problems in Care Transitions to Skilled Nursing Facilities | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/preventing-medication-related-problems-care-transitions-skilled-nursing
      July 31, 2025 - Preventing Medication-Related Problems in Care Transitions to Skilled Nursing Facilities Project Description Publications Research Story Standardizing the hospital-to-skilled nursing facility transition by using a structured handoff between clinical teams along with…

4358. Enabling Shared Decision Making to Reduce Harm from Drug Interactions: An End-to-End Demonstration | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/enabling-shared-decision-making-reduce-harm-drug-interactions-end-end
      January 01, 2023 - Enabling Shared Decision Making to Reduce Harm from Drug Interactions: An End-to-End Demonstration Project Final Report ( PDF , 1.27 MB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not…

4359. High-Performance Work Practices in CLABSI Prevention Interventions (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/clabsi-hpwpreport.pdf
      May 01, 2015 -  Reduced status distinctions—Practices that emphasize egalitarianism across employee roles.

4360. Making It Work Tip Sheet: Empowering Nurses To Implement Nurse-Driven Protocols for Reducing CAUTI in the ICU Setting (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/empowering-nurses.pdf
      April 01, 2022 - Making It Work Tip Sheet: Empowering Nurses To Implement Nurse-Driven Protocols for Reducing CAUTI in the ICU Setting AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI Making It Work Tip Sheet Empowering Nurses To Implement Nurse-Driven Protocols for Reducing CAUTI in the ICU Se…