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psnet.ahrq.gov/node/42584/psn-pdf
September 11, 2013 - Cardiac surgical ICU care: eliminating "preventable"
complications.
September 11, 2013
Shake JG, Pronovost P, Whitman GJR. Cardiac surgical ICU care: eliminating "preventable" complications.
J Card Surg. 2013;28(4):406-13. doi:10.1111/jocs.12124.
https://psnet.ahrq.gov/issue/cardiac-surgical-icu-care-eliminating-p…
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psnet.ahrq.gov/node/41758/psn-pdf
October 10, 2012 - The Broselow tape as an effective medication dosing
instrument: a review of the literature.
October 10, 2012
Meguerdichian MJ, Clapper TC. The Broselow tape as an effective medication dosing instrument: a review
of the literature. J Pediatr Nurs. 2012;27(4):416-420. doi:10.1016/j.pedn.2012.04.009.
https://psnet.ah…
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psnet.ahrq.gov/node/39464/psn-pdf
February 17, 2011 - Evaluation of a redesign initiative in an internal-medicine
residency.
February 17, 2011
McMahon GT, Katz JT, Thorndike ME, et al. Evaluation of a redesign initiative in an internal-medicine
residency. N Engl J Med. 2010;362(14):1304-1311. doi:10.1056/NEJMsa0908136.
https://psnet.ahrq.gov/issue/evaluation-redesign…
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psnet.ahrq.gov/node/46442/psn-pdf
October 04, 2017 - Handoff Communication.
October 4, 2017
APSF Newsletter. October 2017;32:29-56.
https://psnet.ahrq.gov/issue/handoff-communication
Handoff processes are known to carry risks of communication errors. This special issue focuses on
transfers involving anesthesia care. Articles review different types of handoffs, chara…
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psnet.ahrq.gov/node/46998/psn-pdf
August 01, 2019 - 10 Facts on Patient Safety.
June 27, 2018
Patient Safety and Risk Management Service Delivery and Safety. Geneva, Switzerland; World Health
Organization: August 2019.
https://psnet.ahrq.gov/issue/10-facts-patient-safety
This publication highlights statistics that illustrate the global impact of patient harm. The i…
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psnet.ahrq.gov/node/43145/psn-pdf
June 15, 2014 - The 2013 John M. Eisenberg Patient Safety and Quality
Awards.
June 15, 2014
Jt Comm J Qual Patient Saf. 2014;40(5):195-218.
https://psnet.ahrq.gov/issue/2013-john-m-eisenberg-patient-safety-and-quality-awards
Articles in this special issue highlight the achievements of the 2013 John M. Eisenberg Patient Safety and…
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psnet.ahrq.gov/node/44693/psn-pdf
June 15, 2016 - Safety.
June 15, 2016
Center for Health Design.
https://psnet.ahrq.gov/issue/safety-0
Elements of the health care work environment can affect the care delivery. This website highlights design
considerations for health care facilities that can help reduce noise, falls, and hospital-acquired infections.
The collect…
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psnet.ahrq.gov/node/42185/psn-pdf
April 10, 2013 - Improving patient safety in medicine: is the model of
anaesthesia care enough?
April 10, 2013
Haller G. Improving patient safety in medicine: is the model of anaesthesia care enough? Swiss Med Wkly.
2013;143:w13770. doi:10.4414/smw.2013.13770.
https://psnet.ahrq.gov/issue/improving-patient-safety-medicine-model-an…
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psnet.ahrq.gov/node/42664/psn-pdf
August 11, 2014 - Positive deviance: a new tool for infection prevention and
patient safety.
August 11, 2014
Marra AR, Santos OFPD, Neto MC, et al. Positive Deviance: A New Tool for Infection Prevention and
Patient Safety. Curr Infect Dis Rep. 2013.
https://psnet.ahrq.gov/issue/positive-deviance-new-tool-infection-prevention-and-pa…
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psnet.ahrq.gov/node/34617/psn-pdf
March 07, 2005 - World Alliance for Patient Safety: forward programme.
March 7, 2005
Geneva, Switzerland: World Health Organization; 2004.
https://psnet.ahrq.gov/issue/world-alliance-patient-safety-forward-programme
This report outlines the six goals set by the new world alliance to achieve what no single country could
accomplish …
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psnet.ahrq.gov/node/36388/psn-pdf
June 12, 2013 - Using patient safety science to explore strategies for
improving safety in intravenous medication
administration.
June 12, 2013
Franklin M. Journal of the Association for Vascular Access. 2006. 11(3):157–160.
https://psnet.ahrq.gov/issue/using-patient-safety-science-explore-strategies-improving-safety-intravenous-…
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psnet.ahrq.gov/node/40212/psn-pdf
April 04, 2011 - Creating effective quality-improvement collaboratives: a
multiple case study.
April 4, 2011
Strating MMH, Nieboer AP, Zuiderent-Jerak T, et al. Creating effective quality-improvement collaboratives:
a multiple case study. BMJ Qual Saf. 2011;20(4). doi:10.1136/bmjqs.2010.047159.
https://psnet.ahrq.gov/issue/creatin…
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psnet.ahrq.gov/node/45663/psn-pdf
November 09, 2016 - Nursing Home Antimicrobial Stewardship Guide.
November 9, 2016
Rockville, MD: Agency for Healthcare Research and Quality; October 2016.
https://psnet.ahrq.gov/issue/nursing-home-antimicrobial-stewardship-guide
Antimicrobial stewardship is one strategy to reduce health care–associated infections in a variety of
set…
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psnet.ahrq.gov/node/42297/psn-pdf
August 01, 2024 - Society to Improve Diagnosis in Medicine.
August 1, 2024
https://psnet.ahrq.gov/issue/society-improve-diagnosis-medicine
The Society to Improve Diagnosis in Medicine (SIDM) was a not-for-profit organization founded in 2011 that
promoted reducing diagnostic errors through collaboration, research, and education. SIDM…
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www.ahrq.gov/evidencenow/heart-health/cholesterol/statins.html
September 01, 2018 - Strategies to Better Manage Lipids—Statin Pearls
Resource title: Strategies to Better Manage Lipids—Statin Pearls
Resource description: This slide deck and transcript of a 20-minute video with a family physician at Virginia Commonwealth University reviews current recommendations for the use of statins in lo…
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digital.ahrq.gov/ahrq-funded-projects/reducing-hospital-readmission-rates-implementing-inpatient-tobacco-cessation/citation/feasibility
January 01, 2023 - Feasibility of implementing a hospital-based “opt-out” tobacco cessation service.
Citation
Nahhas GJ, Wilson D, Cartmell KB, et al. Feasibility of implementing a hospital-based “opt-out” tobacco cessation service. Nicotine Tob Res 2017 Aug 1;19(8):937-43. PMID: 27928052.
Link
https://www.ncb…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
June 01, 2013 - Spotlight Case July 2008
Spotlight Case
Emergency Error
1
2
Source and Credits
This presentation is based on the June 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
June 01, 2014 - Mixup Beyond the Medication Label
Citation Text:
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
Format:
Google Scholar BibTeX EndNote …
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psnet.ahrq.gov/node/863641/psn-pdf
February 28, 2024 - Revising TeamSTEPPS: The Evolution of Patient Safety
Teamwork Training
February 28, 2024
Haugstetter M, Hines S, Sousane Z, et al. Revising TeamSTEPPS: The Evolution of Patient Safety
Teamwork Training. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork…
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www.ahrq.gov/sites/default/files/2024-10/li-chang-report.pdf
January 01, 2024 - Final Progress Report: Systematic Evaluation of Operating Room Scheduling Across the Perioperative Process
Systematic Evaluation of Operating Room Scheduling Across the Perioperative Process
Principal Investigator: Wei Li, PhD, PE University of Kentucky
Co-Investigators: Phillip K. Chang, MD UK Healthcare
Team Membe…