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psnet.ahrq.gov/issue/using-root-cause-analysis-reduce-falls-injury-community-settings
April 25, 2016 - Study
Using root cause analysis to reduce falls with injury in community settings.
Citation Text:
Lee A, Mills PD, Neily J. Using root cause analysis to reduce falls with injury in community settings. Jt Comm J Qual Patient Saf. 2012;38(8):366-374.
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Goo…
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psnet.ahrq.gov/issue/reducing-harm-patients-using-patient-safety-dashboards-board-level
February 22, 2010 - Newspaper/Magazine Article
Reducing harm to patients. Using patient safety dashboards at the board level.
Citation Text:
Pugh M, Reinertsen JL. Reducing harm to patients. Using patient safety dashboards at the board level. Healthcare executive. 2007;22(6):62, 64-5.
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psnet.ahrq.gov/issue/reducing-risks-complex-care-transitions-rural-areas-grounded-theory
June 23, 2021 - Study
Reducing risks in complex care transitions in rural areas: a grounded theory.
Citation Text:
Winqvist I, Näppä U, Rönning H, et al. Reducing risks in complex care transitions in rural areas: a grounded theory. Int J Qual Stud Health Well-being. 2023;18(1):2185964. doi:10.1080/17482…
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psnet.ahrq.gov/issue/acetaminophen-icon-helps-reduce-medication-decision-errors-experimental-setting
January 12, 2022 - Study
An acetaminophen icon helps reduce medication decision errors in an experimental setting.
Citation Text:
Shiffman S, Cotton H, Jessurun C, et al. An acetaminophen icon helps reduce medication decision errors in an experimental setting. J Am Pharm Assoc (2003). 2016;56(5):495-503.e4…
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psnet.ahrq.gov/issue/systematic-review-unintended-consequences-clinical-interventions-reduce-adverse-outcomes
November 15, 2023 - Review
A systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes.
Citation Text:
Manojlovich M, Lee S, Lauseng D. A Systematic Review of the Unintended Consequences of Clinical Interventions to Reduce Adverse Outcomes. J Patient Saf. 2016;12(…
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www.ahrq.gov/nursing-home/resources/best-practices-social-isolation.html
August 01, 2022 - Best Practices To Help Nursing Home Residents and Their Families To Reduce the Impact of Social Isolation
Resource: Best Practices To Help Nursing Home Residents and Their Families To Reduce the Impact of Social Isolation
This document highlights ways nursing home staff can help residents and families balan…
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digital.ahrq.gov/principal-investigator/abraham-olufunmilola
January 01, 2023 - Abraham, Olufunmilola
Disseminating and Implementing MedSMA℞T Families in Emergency Departments: A Randomized Control Trial to Assess Effectiveness of an Evidence-Based Gaming Intervention to Reduce Opioid Misuse
Description
This research tests the effectiveness of MedSMA℞T Mo…
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digital.ahrq.gov/ahrq-funded-projects/improving-guideline-development-and-implementation/citation/improving
January 01, 2023 - Improving diagnostic testing and reducing overuse of antibiotics for children with pharyngitis: a useful role for the electronic medical record.
Citation
Benin AL, Vitkauskas G, Thornquist E, et al. Improving diagnostic testing and reducing overuse of antibiotics for children with pharyngitis: a usefu…
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digital.ahrq.gov/ahrq-funded-projects/state-and-regional-demonstrations-health-information-technology-currently-known
January 01, 2023 - Does health information exchange reduce unnecessary neuroimaging and improve quality of headache care in the emergency department?
Citation
Bailey JE, Wan JY, Mabry LM, et al. Does health information exchange reduce unnecessary neuroimaging and improve quality of headache care in the emergency departm…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/overview-ptsoffventilator-slides.pptx
January 01, 2017 - Presentation: Program Overview
Overview:
Getting Patients Off the Ventilator Faster
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-25-EF
January 2017
Overview ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
1
Learning Objectives
After this session, you will be …
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/disruptive-behavior-disorders-research-executive-summ.pdf
April 01, 2025 - Executive Summary_Systematic Review: Psychosocial and Pharmacologic Interventions for Disruptive Behavior in Children and Adolescents
Systematic Review
Psychosocial and Pharmacologic
Interventions for Disruptive Behavior in
Children and Adolescents
Executive Summary
Main Points
• When po…
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psnet.ahrq.gov/node/866055/psn-pdf
May 29, 2024 - Reducing Preventable Patient Harm Due to Retained
Surgical Items: The RSI Bundle
May 29, 2024
https://psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
Summary
Retained surgical items (RSIs) cause severe yet preventable patient harm. RSIs are the most common
catego…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-maintenance.pptx
April 01, 2022 - Central Venous Catheter Maintenance
Central Venous Catheter Maintenance
Maintaining Awareness and Proper Care of Catheters in Place
AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI
AHRQ Pub. No. 17(22)-0019
April 2022
1
Step 2. Maintenance
Disrupting the Life Cycle of a Catheter Device1…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/162-example-completed-learning-defects-tool.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
Learning From Defects Tool - Example
ICU & Non-ICU
Problem statement: Healthcare organizations can increase the extent to which they learn from defects. We define this learning as reducing the probability that future patients will be harmed.
What is a defect? A defect is any cli…
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan34/sexually-transmitted-infections-behavioral-counseling-september-2014
May 15, 2013 - Share to Facebook
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archived
Final Research Plan
Sexually Transmitted Infections: Behavioral Counseling
May 15, 2013
Recommendations made by the USPSTF are independent of the U.S. governme…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
February 01, 2012 - Spotlight Case July 2008
Spotlight Case
E-prescribing: E for Error?
1
2
Source and Credits
This presentation is based on the February 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Elisa W. Ashton, PharmD, Assistant Clinical Professor, Departm…
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digital.ahrq.gov/ahrq-funded-projects/using-electronic-data-improve-care-patients-known-or-suspected-cancer/citation/reducing-diagnostic-error
January 01, 2023 - Reducing diagnostic error through medical home-based primary care reform.
Citation
Singh H, Graber M. Reducing diagnostic error through medical home-based primary care reform. JAMA 2010 Jul 28;304(4):463-4.
Link
http://www.ncbi.nlm.nih.gov/pubmed/20664048
Principal Investigator
Singh…
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www.ahrq.gov/patient-safety/settings/esrd/resource/tooldev.html
January 01, 2015 - About the Toolkit Development
ESRD Toolkit
The ESRD Toolkit was developed during a 2-year project called the National Opportunity To Improve Infection Control in End-Stage Renal Disease Facilities, conducted through a partnership that brought together subject matter experts and providers in the field.
Backg…
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www.ahrq.gov/hai/cauti-tools/archived-webinars/reducing-urinary-catheter-use-ed-slides.html
December 01, 2017 - Reducing Unnecessary Urinary Catheter Use in the Emergency Department
Slide Presentation
Slide 1
Reducing Unnecessary Urinary Catheter Use in the Emergency Department
Margarita E. Pena, MD, FACEP
Medical Director, Clinical Decision Unit
St. John Hospital and Medical Center
Detroit, MI
Image: Photo…
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psnet.ahrq.gov/submit-your-toolkit-landing
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Home
Improvement Resources
Toolkits
Toolkit Submissions
PSNet encourages healthcare-related organizations to help make care safer by submitting a Patient Safety Toolkit to support the implementation of products, services, processes, systems, policies, organizational stru…