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psnet.ahrq.gov/issue/using-healthcare-failure-mode-and-effect-analysis-reduce-medication-errors-process-drug
August 23, 2017 - Study
Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug prescription, validation and dispensing in hospitalised patients.
Citation Text:
Vélez-Díaz-Pallarés M, Delgado-Silveira E, Carretero-Accame ME, et al. Using Healthcare Failure Mo…
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psnet.ahrq.gov/issue/chance-favors-only-prepared-mind-preparing-minds-systematically-reduce-hazards-testing
April 23, 2014 - Study
"Chance favors only the prepared mind": preparing minds to systematically reduce hazards in the testing process in primary care.
Citation Text:
Singh R, Hickner J, Mold J, et al. "Chance favors only the prepared mind": preparing minds to systematically reduce hazards in the testin…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/055-patient-instructions-chg-cloths.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Patient Instructions: Cleaning With CHG Cloths
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
What Is Decolonization?
Preoperative Decolonization =
Preemptive treatment to kill bacteria on your body BEFORE surgery,
to r…
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psnet.ahrq.gov/issue/use-design-thinking-and-human-factors-approach-improve-situation-awareness-pediatric
January 19, 2022 - Study
Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit.
Citation Text:
Gifford A, Butcher B, Chima RS, et al. Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive c…
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psnet.ahrq.gov/issue/medication-error-prevention-survey-five-years-results
March 26, 2015 - Study
A medication error prevention survey: five years of results.
Citation Text:
Cusano FL, Chambers C, Summach L. A medication error prevention survey: five years of results. J Oncol Pharm Pract. 2009;15(2):87-93. doi:10.1177/1078155208099284.
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Format:
DOI …
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psnet.ahrq.gov/issue/battling-alarm-fatigue-pediatric-intensive-care-unit
July 22, 2020 - Commentary
Battling alarm fatigue in the pediatric intensive care unit.
Citation Text:
Herrera H, Wood D. Battling alarm fatigue in the pediatric intensive care unit. Crit Care Nurs Clin North Am. 2023;35(3):347-355. doi:10.1016/j.cnc.2023.05.003.
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Format:
DOI …
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/building-capacity/EvidenceNOW-BSC-AL-profile.pdf
September 01, 2021 - EvidenceNOW Building State Capacity Profile: Alabama Cooperative
Alabama Cooperative
Project Name:
Alabama Cardiovascular
Cooperative
Principal Investigators:
Andrea L. Cherrington, MD, MPH
and Elizabeth Jackson, MD, MPH,
FAHA, University of Alabama at
Birmingham
Cooperative Partners:
Alabama Department …
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psnet.ahrq.gov/issue/perceptions-and-attitudes-pediatricians-and-families-regard-pediatric-medication-errors-home
August 11, 2021 - Study
Perceptions and attitudes of pediatricians and families with regard to pediatric medication errors at home.
Citation Text:
de Dios JG, Lopez-Pineda A, Juan GM-P, et al. Perceptions and attitudes of pediatricians and families with regard to pediatric medication errors at home. BMC P…
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psnet.ahrq.gov/issue/which-adverse-events-and-which-drugs-are-implicated-drug-related-hospital-admissions
August 11, 2021 - Review
Which adverse events and which drugs are implicated in drug-related hospital admissions? A systematic review and meta-analysis.
Citation Text:
Haerdtlein A, Debold E, Rottenkolber M, et al. Which adverse events and which drugs are implicated in drug-related hospital admissions? A …
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digital.ahrq.gov/ahrq-funded-projects/examining-feasibility-and-effectiveness-mhealth-solution-designed-enhance
August 01, 2024 - Examining the Feasibility and Effectiveness of an mHealth Solution Designed to Enhance Clinical Outcomes Among Patients Attending Physical Therapy for Musculoskeletal Pain
Project Description
Improving patient engagement in physical therapy (PT) through remote therapeutic monit…
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psnet.ahrq.gov/issue/one-pen-one-patient-achievable-hospital-quality-improvement-project-reduce-risks-inadvertent
April 10, 2024 - Study
Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center.
Citation Text:
Ho S, Stamm R, Hibbs M, et al. Is One-Pen, One-Patient Achievable in the Hospital? A Quality Impr…
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psnet.ahrq.gov/issue/care-transitions-intervention-results-randomized-controlled-trial
July 10, 2008 - Study
Classic
The care transitions intervention: results of a randomized controlled trial.
Citation Text:
Coleman EA, Parry C, Chalmers S, et al. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-8.…
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psnet.ahrq.gov/issue/applying-human-factors-engineering-address-telemetry-alarm-problem-large-medical-center
February 10, 2021 - Study
Applying human factors engineering to address the telemetry alarm problem in a large medical center.
Citation Text:
Patterson ES, Rayo MF, Edworthy JR, et al. Applying human factors engineering to address the telemetry alarm problem in a large medical center. Hum Factors. 2022;64(1…
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psnet.ahrq.gov/issue/prevalence-and-nature-medication-administration-errors-health-care-settings-systematic-review
April 01, 2015 - Review
Prevalence and nature of medication administration errors in health care settings: a systematic review of direct observational evidence.
Citation Text:
Keers RN, Williams SD, Cooke J, et al. Prevalence and nature of medication administration errors in health care settings: a sys…
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psnet.ahrq.gov/node/38886/psn-pdf
August 26, 2009 - Medication overdoses leading to emergency department
visits among children.
August 26, 2009
Schillie SF, Shehab N, Thomas KE, et al. Medication overdoses leading to emergency department visits
among children. Am J Prev Med. 2009;37(3):181-7. doi:10.1016/j.amepre.2009.05.018.
https://psnet.ahrq.gov/issue/medication…
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psnet.ahrq.gov/node/72567/psn-pdf
December 16, 2020 - Transforming the medication regimen review process
using telemedicine to prevent adverse events.
December 16, 2020
Kane?Gill SL, Wong A, Culley CM, et al. Transforming the medication regimen review process using
telemedicine to prevent adverse events. J Am Geriatr Soc. 2020;69(2):530-538. doi:10.1111/jgs.16946.
ht…
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psnet.ahrq.gov/node/43140/psn-pdf
October 31, 2014 - The frequency of diagnostic errors in outpatient care:
estimations from three large observational studies
involving US adult populations.
October 31, 2014
Singh H, Meyer AND, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from
three large observational studies involving US adult popu…
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psnet.ahrq.gov/node/40982/psn-pdf
March 23, 2012 - Emergency hospitalizations for adverse drug events in
older Americans.
March 23, 2012
Budnitz DS, Lovegrove MC, Shehab N, et al. Emergency hospitalizations for adverse drug events in older
Americans. New Engl J Med. 2011;365(21):2002-2012. doi:10.1056/NEJMsa1103053.
https://psnet.ahrq.gov/issue/emergency-hospitali…
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psnet.ahrq.gov/node/46531/psn-pdf
January 24, 2019 - Tracking progress in improving diagnosis: a framework
for defining undesirable diagnostic events.
January 24, 2019
Olson A, Graber ML, Singh H. Tracking Progress in Improving Diagnosis: A Framework for Defining
Undesirable Diagnostic Events. J Gen Intern Med. 2018;33(7):1187-1191. doi:10.1007/s11606-018-4304-2.
ht…
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cds.ahrq.gov/sites/default/files/cds/artifact/136331/Benzodiazepine%20Patient%20Handout.pdf
January 01, 2018 - Microsoft PowerPoint - Updated Handouts - Read-Only
REDUCING MEDICATIONS SAFELY
TO MEET LIFE’S CHANGES … taking:_____________________
Your dose: _____________________________________________
WHY CONSIDER REDUCING … Adapted from “Reducing Medications Safely to Meet Life’s Changes, Focus on Benzodiazepine Receptor Agonists