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psnet.ahrq.gov/node/44488/psn-pdf
September 16, 2015 - Environmental Cleaning for the Prevention of Healthcare-
Associated Infections (HAIs).
September 16, 2015
Leas BF, Sullivan N, Han JH, Pegues DA, Kaczmarek JL, Umscheid CA. Rockville, MD: Agency for
Healthcare Research and Quality; August 2015. Technical Brief No. 22. AHRQ Publication No. 15-
EHC020-EF.
https://p…
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psnet.ahrq.gov/node/836972/psn-pdf
April 20, 2022 - Diagnostic Centers of Excellence: Partnerships to
Improve Diagnostic Safety and Quality (R18).
April 20, 2022
Rockville, MD: Agency for Healthcare Research and Quality; April 7, 2022. RFA-HS-22-008.
https://psnet.ahrq.gov/issue/diagnostic-centers-excellence-partnerships-improve-diagnostic-safety-and-
quality-r18
…
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psnet.ahrq.gov/node/43874/psn-pdf
February 25, 2015 - An overview of the use and implementation of checklists
in surgical specialities - a systematic review.
February 25, 2015
Patel J, Ahmed K, Guru KA, et al. An overview of the use and implementation of checklists in surgical
specialities - a systematic review. Int J Surg. 2014;12(12):1317-23. doi:10.1016/j.ijsu.2014…
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psnet.ahrq.gov/node/45386/psn-pdf
November 23, 2016 - Balancing doctor egos and errors.
November 23, 2016
Sweeney JF. Medical Economics. November 10, 2016.
https://psnet.ahrq.gov/issue/balancing-doctor-egos-and-errors
Disclosure and candor with patients after a medical error has gained support from organizations, clinicians,
and patients. This magazine article discus…
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psnet.ahrq.gov/node/73225/psn-pdf
May 05, 2021 - Black or 'other'? Doctors may be relying on race to make
decisions about your health.
May 5, 2021
Smith J, Spodak C. CNN. April 25, 2021.
https://psnet.ahrq.gov/issue/black-or-other-doctors-may-be-relying-race-make-decisions-about-your-health
Race-adjusted decision making tools perpetuate the potential for diagnos…
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psnet.ahrq.gov/node/48041/psn-pdf
July 10, 2019 - Accuracy of computer-aided diagnosis of melanoma: a
meta-analysis.
July 10, 2019
Dick V, Sinz C, Mittlböck M, et al. Accuracy of Computer-Aided Diagnosis of Melanoma. JAMA Dermatol.
2019;155(11):1291-1299. doi:10.1001/jamadermatol.2019.1375.
https://psnet.ahrq.gov/issue/accuracy-computer-aided-diagnosis-melanoma-m…
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psnet.ahrq.gov/node/44617/psn-pdf
January 22, 2016 - Pediatric prehospital medication dosing errors: a mixed-
methods study.
January 22, 2016
Hoyle JD, Sleight D, Henry R, et al. Pediatric prehospital medication dosing errors: a mixed-methods study.
Prehosp Emerg Care. 2016;20(1):117-124. doi:10.3109/10903127.2015.1061625.
https://psnet.ahrq.gov/issue/pediatric-preh…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-e.pdf
September 01, 2015 - Appendix E. Poster on Urinary Catheter Risks and Indications
AHRQ Safety Program for Reducing CAUTI in Hospitals
Appendix E. Poster on Urinary Catheter Risks
and Indications
■ Acute urinary retention or obstruction
■ Perioperative use in selected surgeries
■ Assistance of healing of severe perineal an…
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psnet.ahrq.gov/node/44358/psn-pdf
September 24, 2016 - Interruptions and medication administration in critical
care.
September 24, 2016
Bower R, Jackson C, Manning JC. Interruptions and medication administration in critical care. Nurs Crit
Care. 2015;20(4):183-95. doi:10.1111/nicc.12185.
https://psnet.ahrq.gov/issue/interruptions-and-medication-administration-critical…
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psnet.ahrq.gov/node/848044/psn-pdf
April 26, 2023 - Effect of a hospital command centre on patient safety: an
interrupted time series study.
April 26, 2023
Mebrahtu TF, McInerney CD, Benn J, et al. BMJ Health Care Inform. 2023;30(1):e100653.
https://psnet.ahrq.gov/issue/effect-hospital-command-centre-patient-safety-interrupted-time-series-study
Command centers…
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psnet.ahrq.gov/node/42128/psn-pdf
August 15, 2013 - Computerized prescriber order entry and opportunities
for medication errors: comparison to tradition paper-
based order entry.
August 15, 2013
Jozefczyk KG, Kennedy WK, Lin MJ, et al. Computerized prescriber order entry and opportunities for
medication errors: comparison to tradition paper-based order entry. J Pha…
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psnet.ahrq.gov/node/866567/psn-pdf
August 21, 2024 - A daily dose of communication to improve quality and
safety outcomes.
August 21, 2024
Halm MA. A daily dose of communication to improve quality and safety outcomes. Am J Crit Care.
2024;33(4):305-310. doi:10.4037/ajcc2024318.
https://psnet.ahrq.gov/issue/daily-dose-communication-improve-quality-and-safety-outcomes…
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psnet.ahrq.gov/node/846455/psn-pdf
March 22, 2023 - Diagnostic Centers of Excellence (X01 Clinical Trial Not
Allowed).
March 22, 2023
PAR-23-120. Bethesda, MD: National Institutes of Health; March 7, 2023
https://psnet.ahrq.gov/issue/diagnostic-centers-excellence-x01-clinical-trial-not-allowed
Approaching diagnosis as a team activity is seen as a key approach to di…
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psnet.ahrq.gov/node/41826/psn-pdf
June 03, 2013 - Effects of an enhanced discharge planning intervention
for hospitalized older adults: a randomized trial.
June 3, 2013
Altfeld SJ, Shier GE, Rooney M, et al. Effects of an enhanced discharge planning intervention for
hospitalized older adults: a randomized trial. Gerontologist. 2013;53(3):430-40. doi:10.1093/geront…
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psnet.ahrq.gov/node/39265/psn-pdf
February 03, 2010 - Intensive care unit alarms—how many do we need?
February 3, 2010
Siebig S, Kuhls S, Imhoff M, et al. Intensive care unit alarms--how many do we need? Crit Care Med.
2010;38(2):451-6. doi:10.1097/CCM.0b013e3181cb0888.
https://psnet.ahrq.gov/issue/intensive-care-unit-alarms-how-many-do-we-need
This study found that …
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psnet.ahrq.gov/node/43996/psn-pdf
November 10, 2018 - When doing wrong feels so right: normalization of
deviance.
November 10, 2018
Price MR, Williams TC. When Doing Wrong Feels So Right: Normalization of Deviance. J Patient Saf.
2018;14(1):1-2. doi:10.1097/PTS.0000000000000157.
https://psnet.ahrq.gov/issue/when-doing-wrong-feels-so-right-normalization-deviance
This…
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psnet.ahrq.gov/node/36711/psn-pdf
July 25, 2011 - Designing decision support for insulin ordering in a
computerized provider order entry system.
July 25, 2011
Wright L, Feldott CC, Hargrove FR. Designing Decision Support for Insulin Ordering in a Computerized
Provider Order Entry System. Hosp Pharm. 2010;42(2). doi:10.1310/hpj4202-158.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/46799/psn-pdf
March 20, 2018 - Seen through the patients' eyes: surgical safety and
checklists.
March 20, 2018
Bergs J, Lambrechts F, Desmedt M, et al. Seen through the patients' eyes: surgical safety and checklists.
Int J Qual Health Care. 2018;30(2):118-123. doi:10.1093/intqhc/mzx180.
https://psnet.ahrq.gov/issue/seen-through-patients-eyes-su…
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psnet.ahrq.gov/node/41976/psn-pdf
March 11, 2013 - Moving beyond readmission penalties: creating an ideal
process to improve transitional care.
March 11, 2013
Burke RE, Kripalani S, Vasilevskis EE, et al. Moving beyond readmission penalties: creating an ideal
process to improve transitional care. J Hosp Med. 2013;8(2):102-9. doi:10.1002/jhm.1990.
https://psnet.ahr…
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psnet.ahrq.gov/node/44274/psn-pdf
February 18, 2019 - Concepts for the development of a customizable checklist
for use by patients.
February 18, 2019
Fernando RJ, Shapiro FE, Rosenberg NM, et al. Concepts for the Development of a Customizable
Checklist for Use by Patients. J Patient Saf. 2019;15(1):18-23. doi:10.1097/PTS.0000000000000203.
https://psnet.ahrq.gov/issue…