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psnet.ahrq.gov/node/847534/psn-pdf
April 12, 2023 - Prevalence and causes of diagnostic errors in
hospitalized patients under investigation for COVID-19.
April 12, 2023
Auerbach AD, Astik GJ, O’Leary KJ, et al. Prevalence and causes of diagnostic errors in hospitalized
patients under investigation for COVID-19. J Gen Intern Med. 2023;38(8):1902-1910. doi:10.1007/s11…
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psnet.ahrq.gov/node/866904/psn-pdf
October 09, 2024 - Crying wolf, alarm safety and management in paediatrics:
a scoping review.
October 9, 2024
Cole R, Roderick G, Cheema O, et al. Crying wolf, alarm safety and management in paediatrics: a scoping
review. J Adv Nurs. 2024;Epub Sep 25. doi:10.1111/jan.16398.
https://psnet.ahrq.gov/issue/crying-wolf-alarm-safety-and-m…
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psnet.ahrq.gov/node/862154/psn-pdf
June 18, 2020 - Listening to women: recommendations from women of
color to improve experiences in pregnancy and birth care.
June 18, 2020
Altman MR, McLemore MR, Oseguera T, et al. Listening to women: recommendations from women of color
to improve experiences in pregnancy and birth care. J Midwifery Womens Health. 2020;65(4):466-4…
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psnet.ahrq.gov/node/862615/psn-pdf
August 12, 2019 - Information and power: women of color's experiences
interacting with health care providers in pregnancy and
birth.
August 12, 2019
Altman MR, Oseguera T, McLemore MR, et al. Information and power: women of color's experiences
interacting with health care providers in pregnancy and birth. Soc Sci Med. 2019;238:1124…
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psnet.ahrq.gov/node/48109/psn-pdf
January 01, 2020 - Dosing errors made by paramedics during pediatric
patient simulations after implementation of a state-wide
pediatric drug dosing reference.
July 24, 2019
Hoyle JD, Ekblad G, Hover T, et al. Dosing Errors Made by Paramedics During Pediatric Patient
Simulations After Implementation of a State-Wide Pediatric Drug Dos…
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psnet.ahrq.gov/node/47907/psn-pdf
July 19, 2019 - Safety-I, Safety-II and burnout: how complexity science
can help clinician wellness.
July 19, 2019
Smaggus A. Safety-I, Safety-II and burnout: how complexity science can help clinician wellness. BMJ Qual
Saf. 2019;28(8):667-671. doi:10.1136/bmjqs-2018-009147.
https://psnet.ahrq.gov/issue/safety-i-safety-ii-and-bur…
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psnet.ahrq.gov/node/854380/psn-pdf
October 11, 2023 - Associations between hospitalist shift busyness,
diagnostic confidence, and resource utilization: a pilot
study.
October 11, 2023
Gupta AB, Greene MT, Fowler KE, et al. Associations between hospitalist shift busyness, diagnostic
confidence, and resource utilization: a pilot study. J Patient Saf. 2023;19(7):447-452…
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psnet.ahrq.gov/node/841787/psn-pdf
December 21, 2022 - Electronic prescribing systems in hospitals to improve
medication safety: a multi-methods research programme.
December 21, 2022
Sheikh A, Coleman JJ, Chuter A, et al. Electronic prescribing systems in hospitals to improve medication
safety: a multimethods research programme. Programme Grants Appl Res. 2022;10(7):1-…
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psnet.ahrq.gov/node/867381/psn-pdf
December 18, 2024 - Promoting medication safety for older adults upon
hospital discharge: guiding principles for a medication
discharge plan.
December 18, 2024
Zhang FH, Lauzon J, Payette J, et al. Promoting medication safety for older adults upon hospital discharge:
guiding principles for a medication discharge plan. Br J Clin Pharm…
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psnet.ahrq.gov/node/74719/psn-pdf
February 02, 2022 - Failure to rescue following emergency surgery: a FRAM
analysis of the management of the deteriorating patient.
February 2, 2022
Sujan M, Bilbro N, Ross A, et al. Failure to rescue following emergency surgery: A FRAM analysis of the
management of the deteriorating patient. Appl Ergon. 2022;98:103608. doi:10.1016/j.a…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/identifying-delirium.pdf
June 01, 2021 - Identifying Delirium
IDENTIFYING DELIRIUM
ABCs OF IDENTIFICATION
Acute/subacute
• Altered mental status with
change in attention
Behavioral disturbance
• (Restless, agitated, combative)
Changes in consciousness
• (Jittery, drowsy, difficult to
arouse)
COMMON CAUSES OF DELIRIUM
COMMON…
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T2-Sample_Procedures_Phase_3.pdf
May 01, 2014 - Sample Vignettes
Advancing Excellence in Health Care www.ahrq.gov
Agency for Healthcare Research and Quality HAIs
Healthcare-
Associated
Infections
PREVENT
Comprehensive Antibiogram Toolkit: Phase 3
Sample Procedures1
[NURSING HOME NAME]
[DATE]
Purpose and Scope
This procedure covers the use of an antibio…
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T1-Sample_Policy_Phase_3.doc
May 01, 2014 - Comprehensive Antibiogram Toolkit: Phase 3
Sample Policy
[NAME OF NURSING HOME]
RE: Antibiogram Program
[DATE]
Antibiotics are among the most commonly prescribed pharmaceuticals in long-term care settings, yet reports indicate that a high proportion of antibiotic prescriptions are inappropriate. The adverse consequ…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/infection-prevention/hand-hygiene/skills-test.html
March 01, 2017 - Training Module 1—Skills Questions
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
The How-To's of Hand Hygiene
How long should you rub your hands with soap when you are hand washing?
At least 5 seconds
At least 15 seconds
At least 30 seconds
At least 60 seconds
How long …
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pso.ahrq.gov/resources
October 01, 2024 - SHARE:
More topics in this section
Resources
Resources
Resources About the Patient Safety and Quality Improvement Act of 2005
Resources for Improving Patient Safety and Healthcare Quality
Resources for Artificial Intelligence (AI) in …
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www.ahrq.gov/ncepcr/research/disseminating-evidence/index.html
April 01, 2025 - Disseminating Evidence into Practice
AHRQ disseminates the most up-to-date evidence and tools into practices so that they can implement evidence-based practices to improve the care of their patients. AHRQ synthesizes the evidence and disseminates it through programs such as its Evidence-Based Practice Centers, …
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide73.html
October 01, 2014 - 73. For the Patient Unwilling To Quit (Continued)
Treating Tobacco Use and Dependence: 2008 Update
Text version of slide presentation.
The "5 Rs"
Rewards
The clinician should ask the patient to identify potential benefits of stopping tobacco use. The clinician may suggest and highlight those tha…
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www.ahrq.gov/hai/tools/mvp/modules.html
January 01, 2017 - Toolkit Modules
The toolkit consists of four modules and other resources that will help ICUs uncover local defects, implement interventions to prevent ventilator-associated events, and build a sustainable safety culture.
Module on How To Apply CUSP for Mechanically Ventilated Patients
The Comprehensive Unit…
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www.ahrq.gov/hai/cauti-tools/ena-slides/index.html
February 01, 2023 - The Emergency Nurses Association Presents CAUTI Slides and Transcript
Next Page
Table of Contents
The Emergency Nurses Association Presents CAUTI Slides and Transcript
Opening Materials: Attribution, Objectives, Introduction, and Main Menu
Part One: Traditional Practice and Recommendations for Cha…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-i.docx
June 02, 2025 - AHRQ Safety Program for Reducing CAUTI in Hospitals
Appendix I. Catheter Care Pocket Card
Interventions To Prevent CAUTI in Patients Who Have a Documented Medical Need for Indwelling Urinary Catheter
Prevention strategies must focus on clear indications for the insertion of a urinary catheter and prompt removal w…