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psnet.ahrq.gov/node/73239/psn-pdf
May 12, 2021 - Patient factors associated with new prescribing of
potentially inappropriate medications in multimorbid US
older adults using multiple medications.
May 12, 2021
Jungo KT, Streit S, Lauffenburger JC. Patient factors associated with new prescribing of potentially
inappropriate medications in multimorbid US older adu…
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www.ahrq.gov/sites/default/files/2025-06/nishisaki3-report.pdf
January 01, 2025 - Final Progress Report: Improving the safety of pediatric tracheal intubation in ICUs with apneic oxygenation and video laryngoscopes
Title: Improving the safety of pediatric tracheal intubation in ICUs with
apneic oxygenation and video laryngoscopes
Principal Investigator: Akira Nishisaki, MD, MSCE
Co-Investigator…
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psnet.ahrq.gov/node/865455/psn-pdf
March 27, 2024 - Communication During Transitions of Care
March 27, 2024
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/communication-during-transitions-care
Introduction
Inaccurate or untimely communication and ineffective teamwork in healthca…
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psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - SPOTLIGHT CASE
Failure to Report
Citation Text:
Spath P. Failure to Report. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
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psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia
Citation Text:
Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/node/49636/psn-pdf
October 01, 2011 - Mobility Lost in the ICU
October 1, 2011
Smith J. Mobility Lost in the ICU. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/mobility-lost-icu
Case Objectives
Describe the role of the physical therapist in the hospital and ICU.
Compare the risks from immobility with the benefits gained from a program of ther…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/043-vap-prevention-notes.docx
October 01, 2024 - It reduces the risk of gastrointestinal complications such as gastric distention and reflux, as well
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psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle
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May 29, 2024
View more articles from the same authors.
Inno…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/VpT-c4bnmvHFRPyKgPwb2Z
December 01, 2010 - Community-based
group exercise improves balance and reduces falls in at-risk older people: a ran-
domised … Alfacalcidol reduces the number of fallers in a community-
dwelling elderly population with a minimum
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psnet.ahrq.gov/node/49768/psn-pdf
September 01, 2016 - A Pill Organizing Plight
September 1, 2016
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/pill-organizing-plight
Case Objectives
Identify patients at high risk for adverse drug events.
List drugs that are considered inappropriate in older patients.
…
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx
Spotlight
Overdose of Gabapentin and Oxycodone in a Patient
with End-Stage Renal Disease: A Case for Appropriate
Interruptive Drug-Disease Alerts
Source and Credits
• This presentation is based on the January 2023 AHRQ WebM&M
Spotl…
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effectivehealthcare.ahrq.gov/sites/default/files/11_peptic_ulcer_potential_high_impact_2012-12-111.pdf
January 01, 2012 - PEPTIC ULCER #11
AHRQ Healthcare Horizon Scanning System – Potential
High-Impact Interventions Report
Priority Area 11: Peptic Ulcer Disease and Dyspepsia
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
ww…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
December 01, 2017 - Accessible Facilitator Guide: Learn From Defects for Sustainability
Slide Title and Commentary
Slide Number and Slide
Sustainability: Learning From Defects
SAY:
This module will review some concepts from Learning From Defects Through Sensemaking. It will also cover the Learning From Defects process from the per…
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www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
December 01, 2017 - Sustainability: Learning From Defects: Facilitator Notes
AHRQ Safety Program for Surgery
Slide 1: Sustainability: Learning From Defects
Say:
This module will review some concepts from Learning From Defects Through Sensemaking. It will also cover the Learning From Defects process from the perspective of …
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www.ahrq.gov/sites/default/files/2024-09/secola-report.pdf
January 01, 2024 - Final Progress Report: Central Venous Catheter (CVC)–Related Bloodstream Infections in Pediatric Cancer
1
Central Venous Catheter (CVC)–Related Bloodstream Infections in Pediatric Cancer
Principal Investigator: Rita Secola, RN, PhD, CPON
Organization: University of California Los Angeles, NIHAward@research.ucla.e…
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www.ahrq.gov/patient-safety/settings/multiple/project-echo/videos.html
April 01, 2021 - Videos About Telementoring and COVID-19
AHRQ grantee and Project ECHO founder Dr. Sanjeev Arora, M.D., took part in an in-depth interview with AHRQ's Office of Communications as the COVID-19 pandemic continued to unfold. In these video clips, Dr. Arora describes AHRQ's contribution to this innovative model, h…
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www.ahrq.gov/news/newsroom/case-studies/201718.html
April 01, 2018 - Los Angeles County Health Center Uses CAHPS To Shorten Wait Times
Search All Impact Case Studies
April 2018
Feedback from patients on AHRQ's Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS) told officials at San Fernando, CA-based Northeast Valley Health Corporat…
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www.ahrq.gov/hai/clabsi-tools/appendix-9.html
March 01, 2018 - Appendix 9: Back to Basics
Tools for Reducing Central Line-Associated Blood Stream Infections
These tools will help your unit implement evidence-based practices and eliminate central line-associated blood stream infections (CLABSI). When used with the CUSP (Comprehensive Unit-based Safety Program) Toolkit, th…
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digital.ahrq.gov/2020-year-review/research-summary/improving-care-transitions-hospitalized-patients-pharmacy-integrated-transitions-program
January 01, 2020 - Improving Care Transitions of Hospitalized Patients With the Pharmacy Integrated Transitions Program
Standardizing the hospital-to-skilled nursing facility transition by using a structured handoff between clinical teams along with a pharmacist to monitor patient medications during the transition may improve care co…
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psnet.ahrq.gov/issue/10-patient-safety-tips-hospitals
December 09, 2009 - Fact Sheet/FAQs
Classic
10 Patient Safety Tips for Hospitals.
Citation Text:
10 Patient Safety Tips for Hospitals. Rockville, MD: Agency for Healthcare Research and Quality; December 2009. AHRQ Publication No. 10-M008.
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