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psnet.ahrq.gov/node/47572/psn-pdf
January 23, 2019 - In patient safety efforts, pharmacists gain new
prominence.
January 23, 2019
Gale R. In Patient Safety Efforts, Pharmacists Gain New Prominence. Health Aff (Millwood).
2018;37(11):1726-1729. doi:10.1377/hlthaff.2018.1225.
https://psnet.ahrq.gov/issue/patient-safety-efforts-pharmacists-gain-new-prominence
This com…
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psnet.ahrq.gov/node/45679/psn-pdf
January 03, 2018 - Global Guidelines on the Prevention of Surgical Site
Infection.
January 3, 2018
Global Guidelines on the Prevention of Surgical Site Infection.
https://psnet.ahrq.gov/issue/global-guidelines-prevention-surgical-site-infection
Efforts to reduce surgical site infections have achieved some success. The World Health O…
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psnet.ahrq.gov/node/43213/psn-pdf
June 04, 2014 - Back to basics: preventing surgical site infections.
June 4, 2014
Spruce L. Back to basics: preventing surgical site infections. AORN J. 2014;99(5):600-8; quiz 609-11.
doi:10.1016/j.aorn.2014.02.002.
https://psnet.ahrq.gov/issue/back-basics-preventing-surgical-site-infections
Surgical site infections are a common …
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psnet.ahrq.gov/node/50776/psn-pdf
January 08, 2020 - Application of human factors to improve usability of
clinical decision support for diagnostic decision-making:
a scenario-based simulation study.
January 8, 2020
Carayon P, Hoonakker P, Hundt AS, et al. Application of human factors to improve usability of clinical
decision support for diagnostic decision-making: a…
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psnet.ahrq.gov/node/50904/psn-pdf
February 19, 2020 - The harms of promoting 'Zero Harm'.
February 19, 2020
Thomas EJ. The harms of promoting ‘Zero Harm’. BMJ Qual Saf. 2019;29(1):4-6. doi:10.1136/bmjqs-2019-
009703.
https://psnet.ahrq.gov/issue/harms-promoting-zero-harm
Achieving “zero harm” has been advocated as a patient safety goal. This editorial proposes that t…
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psnet.ahrq.gov/node/73871/psn-pdf
September 22, 2021 - Making Health Care Safer in Ambulatory Care Settings
and Long-term Care Facilities (R18).
September 22, 2021
Rockville, MD: Agency for Healthcare Research and Quality; September 9, 2021. PA-21-267.
https://psnet.ahrq.gov/issue/making-health-care-safer-ambulatory-care-settings-and-long-term-care-
facilities-r…
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www.ahrq.gov/ncepcr/communities/pbrn/registry/southern-illinois-practice-research-organization.html
January 01, 2012 - Southern Illinois Practice Research Organization
Status:
Inactive
Registered Date:
January 1, 2012
PBRN Acronym:
SIPRO
PBRN Type:
Mixed Network (a combination of family medicine, internal medicine, pediatrics, nursing and/or other specialties)
Other
PBRN Type Other:
Non-a…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/aph.html
August 01, 2022 - Event Investigation and Analysis Guide: Appendix H
Hierarchy of Solutions
Do solutions meet the following criteria:
Address the root cause/contributing factor.
Are specific and concrete.
Can be understood and implemented by a reader unfamiliar with the situation.
Will be tested or simulated prior to…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/tips.html
March 01, 2017 - Tips for Implementing Interventions
These tips are to help educators prepare for a live training session and facilitate an interactive experience.
Reinforce that the session focuses on ways the team can work together to improve resident safety and reduce catheter-associated urinary tract infections (CAUTIs)…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults4.html
September 01, 2024 - State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults
Conclusion
Previous Page Next Page
Table of Contents
State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults
Introduction
Unique Challenges in Approaching Diagnostic Safety in …
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide77.html
October 01, 2014 - 77. For the Patient Who Has Recently Quit (Continued)
Treating Tobacco Use and Dependence: 2008 Update
Text version of slide presentation.
Addressing problems encountered by former smokers (Continued)
Weight gain
Recommend starting or increasing physical activity.
Reassure the patient that…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apa_gtube.pdf
June 02, 2025 - NICU Toolkit, Appendix A, Gastrostomy Tube
Gastrostomy Tube (G Tube or Button)
Giving medicines and feeding if your baby has a
gastrostomy tube:
■ Clear the G tube or button as your health care provider showed you.
■ Check for placement of the G tube or button.
■ Slowly push in liquid medicine or feeding with…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-1.html
September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction
Introduction
Previous Page Next Page
Table of Contents
Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction
Introduction
Rationale for Use
Content-Specific Versus Process-Focused Checklis…
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psnet.ahrq.gov/node/837206/psn-pdf
May 25, 2022 - Automated dispensing cabinet overrides-an evaluation of
necessity in a pediatric emergency department.
May 25, 2022
Paterson EP, Manning KB, Schmidt MD, et al. Automated dispensing cabinet overrides-an evaluation of
necessity in a pediatric emergency department. J Emerg Nurs. 2022;48(3):319-327.
doi:10.1016/j.jen.…
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psnet.ahrq.gov/node/60828/psn-pdf
August 19, 2020 - When COVID-19 hit, many elderly were left to die.
August 19, 2020
Stevis-Gridneff M, Apuzzo M, Pronczuk M. When COVID-19 hit, many elderly were left to die. New York
Times. 2020;August 8.
https://psnet.ahrq.gov/issue/when-covid-19-hit-many-elderly-were-left-die
Residential care facilities have been challenged by C…
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psnet.ahrq.gov/node/39460/psn-pdf
March 23, 2011 - Applying root cause analysis to improve patient safety:
decreasing falls in postpartum women.
March 23, 2011
Chen K-H, Chen L-R, Su S. Applying root cause analysis to improve patient safety: decreasing falls in
postpartum women. Qual Saf Health Care. 2010;19(2):138-43. doi:10.1136/qshc.2008.028787.
https://psnet.a…
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psnet.ahrq.gov/node/44183/psn-pdf
November 03, 2015 - The absence of a drug–disease interaction alert leads to a
child's death.
November 3, 2015
ISMP Medication Safety Alert! Acute Care Edition. May 21, 2015;20:1-4.
https://psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death
The disabling of alerts due to alarm fatigue can hinder the abilit…
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psnet.ahrq.gov/node/853062/psn-pdf
August 30, 2023 - Quality and safety practices among academic obstetrics
and gynecology departments.
August 30, 2023
Christopher D, Leininger WM, Beaty L, et al. Quality and safety practices among academic obstetrics and
gynecology departments. Am J Med Qual. 2023;38(4):165-173. doi:10.1097/jmq.0000000000000129.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/44675/psn-pdf
July 05, 2016 - Why July matters.
July 5, 2016
Petrilli CM, Del Valle J, Chopra V. Why July Matters. Acad Med. 2016;91(7):910-912.
doi:10.1097/ACM.0000000000001196.
https://psnet.ahrq.gov/issue/why-july-matters
Studies have reached conflicting conclusions about whether the "July Effect"—the belief that inpatient
mortality increa…
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psnet.ahrq.gov/node/45376/psn-pdf
November 09, 2016 - The new CMS hospital quality star ratings: the stars are
not aligned.
November 9, 2016
Bilimoria KY, Barnard C. The New CMS Hospital Quality Star Ratings: The Stars Are Not Aligned. JAMA.
2016;316(17):1761-1762. doi:10.1001/jama.2016.13679.
https://psnet.ahrq.gov/issue/new-cms-hospital-quality-star-ratings-stars-a…