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www.ahrq.gov/news/newsroom/case-studies/201706.html
May 01, 2017 - Pennsylvania Psychiatric Institute Slashes Readmission Rates with AHRQ-based Discharge Program
Search All Impact Case Studies
May 2017
The Pennsylvania Psychiatric Institute in Harrisburg reduced its 30-day readmission rate from 20 percent in 2013 to 10.4 percent in 2015 after implementing a discharge progr…
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www.ahrq.gov/hai/cauti-tools/impl-guide/index.html
October 01, 2015 - Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Next Page
Table of Contents
Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Overview
Frameworks for Change and Improvement
Technical…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-new-sops-workplace-safety-mcgaffigan.pdf
December 01, 2020 - New AHRQ SOPS® Workplace Safety Supplemental Items for Hospitals - McGaffigan
Workforce
Safety
Patricia McGaffigan, RN, MS, CPPS
pmcgaffigan@ihi.org; @Pmcgaffigan_IHI
mailto:pmcgaffigan@ihi.org
Why Workforce Safety Matters
Workforce safety is
essential for safe, high-
quality care and is
preconditional to …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.pdf
January 01, 2010 - Strategy 4: IDEA Discharge Planning (Tool 3)
Guide to Patient and Family Engagement :: 1
Improving Discharge Outcomes with Patients and Families
Evidence for engaging patients
and families in discharge planning
Nearly 20 percent of patients experience an adverse
event within 30 days of discharge.1,2 Re…
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www.ahrq.gov/hai/tools/mrsa-prevention/surgery/index-clinical-topics.html
April 01, 2025 - MRSA Prevention Toolkit: Targeting SSI
Index of Clinical Topics
Previous Page Next Page
Table of Contents
MRSA Prevention Toolkit: Targeting SSI
The Four Key Strategies of MRSA Prevention: Targeting SSI
MRSA and SSI Prevention Phases
Importance of MRSA and SSI Prevention
MRSA Surveillance
…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/mcc-summit/mcc-summit-arlene.pdf
November 17, 2020 - Transforming Care for People Living with Multiple Chronic Conditions
Transforming Care for People Living with
Multiple Chronic Conditions
Arlene Bierman, M.D., M.S.
Director, Center for Evidence and Practice Improvement
Agency for Healthcare Research and Quality
November 17, 2020
Why MCC?
• Common, Costly
• H…
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www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/lessons.html
August 01, 2022 - Demonstration Grants Final Evaluation Report
Lessons Learned From Implementation Challenges
Previous Page Next Page
Table of Contents
Demonstration Grants Final Evaluation Report
Executive Summary
Detailed Findings
Evaluation Issues
Contributions to Patient Safety and Medical Liability
L…
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www.ahrq.gov/hai/cusp/clabsi-hpwpreport/index.html
August 01, 2015 - High-Performance Work Practices in CLABSI Prevention Interventions
Next Page
Table of Contents
High-Performance Work Practices in CLABSI Prevention Interventions
Case Studies
Key Findings
Conclusions
References
Table 1. Case Study Sites
Table 2. Summary of Key Informants, All Sites
Tabl…
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digital.ahrq.gov/program-overview/research-stories/patient-facing-app-improve-care-transitions-hospital-home
January 01, 2023 - A Patient-Facing App to Improve Care Transitions from Hospital to Home
Theme:
Engaging and Empowering Patients and Caregivers
Subtheme:
Using Digital Healthcare Tools in Chronic Disease Self-Management
A patient-facing app simplifying the information patients and caregivers receive has the…
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psnet.ahrq.gov/issue/root-cause-analysis-cases-involving-diagnosis
August 28, 2019 - Commentary
Root cause analysis of cases involving diagnosis.
Citation Text:
Graber ML, Castro GM, Danforth M, et al. Root cause analysis of cases involving diagnosis. Diagnosis (Berl). 2024;11(4):353-368. doi:10.1515/dx-2024-0102.
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Format:
DOI Google Scholar Bi…
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digital.ahrq.gov/ahrq-funded-projects/development-and-implementation-remote-telehealth-user-reported-cancer
September 30, 2023 - Development and Implementation of the REmote Telehealth User-Reported caNcer Surveillance (RETURNS) Program for Lung Cancer
Project Description
The ability to remotely collect and review signs and symptoms of lung cancer recurrence using patient-reported outcomes and results of…
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psnet.ahrq.gov/issue/guide-patient-and-family-engagement-hospital-quality-and-safety
December 24, 2008 - Multi-use Website
Guide to Patient and Family Engagement in Hospital Quality and Safety.
Citation Text:
Guide to Patient and Family Engagement in Hospital Quality and Safety. Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
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…
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digital.ahrq.gov/health-care-theme/adverse-events
January 01, 2023 - Adverse Events
Implementation of DDInteract: A Shared Decision Making Tool for Anticoagulant Drug-Drug Interactions
Description
This research will implement, evaluate, and disseminate DDInteract, a shared decision making clinical decision support tool that aims to reduce harm …
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psnet.ahrq.gov/issue/pediatric-diagnostic-safety-state-science-and-future-directions
August 16, 2023 - Book/Report
Pediatric Diagnostic Safety: State of the Science and Future Directions.
Citation Text:
Pediatric Diagnostic Safety: State of the Science and Future Directions. Grubenhoff JA, Cifra CL, Marshall T, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 20…
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psnet.ahrq.gov/issue/how-can-we-make-diagnosis-safer
April 12, 2014 - Commentary
How can we make diagnosis safer?
Citation Text:
Schiff G, Leape L. Commentary: how can we make diagnosis safer? Acad Med. 2012;87(2):135-138. doi:10.1097/ACM.0b013e31823f711c.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML End…
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psnet.ahrq.gov/issue/identifying-causes-adverse-events-detected-automated-trigger-tool-through-depth-analysis
October 05, 2011 - Study
Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.
Citation Text:
Muething SE, Conway PH, Kloppenborg E, et al. Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis. Qual Saf Health…
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psnet.ahrq.gov/issue/incidence-and-nature-prescribing-and-medication-administration-errors-paediatric-inpatients
July 08, 2008 - Study
The incidence and nature of prescribing and medication administration errors in paediatric inpatients.
Citation Text:
Ghaleb M, Barber N, Franklin BD, et al. The incidence and nature of prescribing and medication administration errors in paediatric inpatients. Arch Dis Child. 201…
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psnet.ahrq.gov/issue/american-college-endocrinology-and-american-association-clinical-endocrinologists-position
August 20, 2018 - Commentary
American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology.
Citation Text:
Bates DW, Clark NG, Cook RI, et al. American College of Endocrinology and Amer…
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psnet.ahrq.gov/issue/transition-care-hospitalized-elderly-patients-development-discharge-checklist-hospitalists
November 16, 2022 - Commentary
Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists.
Citation Text:
Halasyamani L, Kripalani S, Coleman E, et al. Transition of care for hospitalized elderly patients—Development of a discharge checklist for hospitalists…
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psnet.ahrq.gov/issue/evaluation-collaborative-safety-focused-nurse-pharmacist-intervention-improving-accuracy
April 28, 2010 - Study
An evaluation of a collaborative, safety focused, nurse–pharmacist intervention for improving the accuracy of the medication history.
Citation Text:
Henneman EA, Tessier EG, Nathanson BH, et al. An evaluation of a collaborative, safety focused, nurse-pharmacist intervention for imp…