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effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-IV-high-risk-drugs-rapid-response.pdf
January 01, 2024 - of anticoagulation
in the ambulatory setting improved time in therapeutic range, and
telepharmacy reduced … telemedicine and self-testing statistically significantly improved TTR compared to
usual care; while it also reduced … number of patients enrolled per
pharmacy, or the number of pharmacies providing the service, which
reduced … therapeutic
range (MD 9.50%; 95% CI,
3.16–15.85; I2 = 87%; P< 0.01)
• The combined intervention
reduced
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-removal-notes.docx
April 01, 2022 - Central Venous Catheter Removal Facilitator Notes
CLABSI Module:
Central Venous Catheter Removal
Facilitator Guide
Slide Number and Image
This module, titled Central Venous Catheter Removal, is part of the Agency for Healthcare Research and Quality’s Safety Program for intensive care units (ICUs). The module ad…
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effectivehealthcare.ahrq.gov/sites/default/files/interventions-horizon-scan-high-impact-1306.pdf
June 01, 2013 - Experts expected to see the program’s most
dramatic effects in reduced health care costs, improved … thought that physicians would likely appreciate the
support to care for patients in their homes and the reduced … could be recouped over time as inappropriate ED visits and hospitalizations and
readmissions are reduced … They noted the potential for improved patient outcomes and the
reduced number of hospital admissions
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datatools.ahrq.gov/nhqdr/resources-addressing-disparities-and-improving-quality/
January 01, 2022 - Skip to main content
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psnet.ahrq.gov/innovations
February 26, 2025 - Innovations
The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …
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digital.ahrq.gov/principal-investigator/koppel-ross
January 01, 2023 - Koppel, Ross
Guide to reducing unintended consequences of electronic health records.
Citation
Jones SS, Koppel R, Ridgely MS, et al. Guide to reducing unintended consequences of electronic health records. (Prepared by RAND Corporation under Contract No. 290-06-0017-5). AHRQ Pu…
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psnet.ahrq.gov/node/845652/psn-pdf
March 14, 2023 - Controlled substance drug diversion by healthcare
workers as a threat to patient safety.
March 14, 2023
ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4):1-4; March 9, 2023:28(5):1-4.
https://psnet.ahrq.gov/issue/controlled-substance-drug-diversion-healthcare-workers-threat-patient-safety
D…
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psnet.ahrq.gov/node/47148/psn-pdf
June 25, 2018 - Necessity for a pathway for "high-alert" patients.
June 25, 2018
Shane R, Amer K, Noh L, et al. Necessity for a pathway for "high-alert" patients. Am J Health Syst Pharm.
2018;75(13):993-997. doi:10.2146/ajhp170397.
https://psnet.ahrq.gov/issue/necessity-pathway-high-alert-patients
Medication errors can contribute…
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psnet.ahrq.gov/node/838081/psn-pdf
September 14, 2022 - Medication dosage calculation among nursing students:
does digital technology make a difference? A literature
review.
September 14, 2022
Stake-Nilsson K, Almstedt M, Fransson G, et al. Medication dosage calculation among nursing students:
does digital technology make a difference? A literature review. BMC Nurs. 20…
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psnet.ahrq.gov/node/45650/psn-pdf
December 14, 2016 - Are physicians safely prescribing opioids for chronic
noncancer pain? A systematic review of current evidence.
December 14, 2016
Tournebize J, Gibaja V, Muszczak A, et al. Are Physicians Safely Prescribing Opioids for Chronic
Noncancer Pain? A Systematic Review of Current Evidence. Pain Pract. 2016;16(3):370-83.
d…
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psnet.ahrq.gov/node/73566/psn-pdf
August 04, 2021 - Personal formularies of primary care physicians across 4
health care systems.
August 4, 2021
Galanter W, Eguale T, Gellad WF, et al. Personal formularies of primary care physicians across 4 health
care systems. JAMA Netw Open. 2021;4(7):e2117038. doi:10.1001/jamanetworkopen.2021.17038.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/47783/psn-pdf
April 10, 2019 - An IDEA: safety training to improve critical thinking by
individuals and teams.
April 10, 2019
Browne AM, Deutsch ES, Corwin K, et al. An IDEA: Safety Training to Improve Critical Thinking by
Individuals and Teams. Am J Med Qual. 2019;34(6):569-576. doi:10.1177/1062860618820687.
https://psnet.ahrq.gov/issue/idea-s…
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psnet.ahrq.gov/node/47542/psn-pdf
January 16, 2019 - Utilizing a Systems and Design Thinking Approach for
Improving Well-Being Within Health Professional
Education and Health Care.
January 16, 2019
Kreitzer MJ, Carter K, Coffey DS, et al. NAM Perspectives. Washington, DC: National Academy of
Medicine; 2019.
https://psnet.ahrq.gov/issue/utilizing-systems-and-design-…
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psnet.ahrq.gov/node/837073/psn-pdf
May 11, 2022 - Clinical progress note: situation awareness for clinical
deterioration in hospitalized children.
May 11, 2022
Sosa T, Galligan MM, Brady PW. Clinical progress note: situation awareness for clinical deterioration in
hospitalized children. J Hosp Med. 2022;17(3):199-202. doi:10.1002/jhm.2774.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/73530/psn-pdf
July 28, 2021 - The nature, severity and causes of medication incidents
from an Australian community pharmacy incident
reporting system: the QUMwatch study.
July 28, 2021
Adie K, Fois RA, McLachlan AJ, et al. The nature, severity and causes of medication incidents from an
Australian community pharmacy incident reporting system: T…
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psnet.ahrq.gov/node/46088/psn-pdf
May 24, 2017 - Innovative use of the electronic health record to support
harm reduction efforts.
May 24, 2017
Hyman D, Neiman J, Rannie M, et al. Innovative Use of the Electronic Health Record to Support Harm
Reduction Efforts. Pediatrics. 2017;139(5). doi:10.1542/peds.2015-3410.
https://psnet.ahrq.gov/issue/innovative-use-elect…
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psnet.ahrq.gov/node/47495/psn-pdf
October 31, 2018 - Developing and evaluating clinical leadership
interventions for frontline healthcare providers: a review
of the literature.
October 31, 2018
Mianda S, Voce A. Developing and evaluating clinical leadership interventions for frontline healthcare
providers: a review of the literature. BMC Health Serv Res. 2018;18(1):…
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psnet.ahrq.gov/node/47224/psn-pdf
June 27, 2018 - Managing Alarms in Acute Care Across the Life Span:
Electrocardiography and Pulse Oximetry.
June 27, 2018
Managing Alarms in Acute Care Across the Life Span: Electrocardiography and Pulse Oximetry. Crit Care
Nurse. 2018;38(2):e16-e20. doi:10.4037/ccn2018468.
https://psnet.ahrq.gov/issue/managing-alarms-acute-care-…
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psnet.ahrq.gov/node/36698/psn-pdf
February 24, 2011 - The impact of duty hours on resident self reports of
errors.
February 24, 2011
Vidyarthi A, Auerbach AD, Wachter R, et al. The impact of duty hours on resident self reports of errors. J
Gen Intern Med. 2007;22(2):205-9.
https://psnet.ahrq.gov/issue/impact-duty-hours-resident-self-reports-errors
Residency programs…
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psnet.ahrq.gov/node/866270/psn-pdf
July 10, 2024 - Identifying and measuring administrative harms
experienced by hospitalists and administrative leaders.
July 10, 2024
Burden M, Astik GJ, Auerbach AD, et al. Identifying and measuring administrative harms experienced by
hospitalists and administrative leaders. JAMA Intern Med. 2024;184(9):1014-1023.
doi:10.1001/jam…