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psnet.ahrq.gov/issue/drawn-curtains-muted-alarms-and-diverted-attention-lead-tragedy-postanesthesia-care-unit
June 10, 2018 - Newspaper/Magazine Article
Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit.
Citation Text:
Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit. ISMP Medication Safety Alert! Acute Care E…
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psnet.ahrq.gov/issue/improving-patient-care-my-right-knee
August 04, 2021 - Commentary
Improving patient care. My right knee.
Citation Text:
Berwick DM. Improving patient care. My right knee. Ann Intern Med. 2005;142(2):121-5.
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psnet.ahrq.gov/issue/open-notes-shines-light-errors-patient-medical-records-will-new-rule-lead-flood-correction
March 27, 2024 - Newspaper/Magazine Article
Open Notes shines light on errors in patient medical records — will the new rule lead to a flood of correction requests?
Citation Text:
Open Notes shines light on errors in patient medical records — will the new rule lead to a flood of correction requests? Clar…
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psnet.ahrq.gov/issue/drug-shortages-continue-compromise-patient-care
February 24, 2016 - Newspaper/Magazine Article
Drug shortages continue to compromise patient care.
Citation Text:
Drug shortages continue to compromise patient care. ISMP Medication Safety Alert! Acute Care Edition. January 11, 2018;23:1-4.
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psnet.ahrq.gov/issue/health-informatics-healthcare-quality-and-safety-and-healthcare-simulation-new-triad-advance
April 28, 2021 - Special or Theme Issue
Health Informatics, Healthcare Quality and Safety, and Healthcare Simulation: the New Triad to Advance Healthcare Operations
Citation Text:
Health Informatics, Healthcare Quality and Safety, and Healthcare Simulation: the New Triad to Advance Healthcare Operations …
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psnet.ahrq.gov/issue/patient-safety-20-slaying-dragons-not-just-investigating-them
September 14, 2016 - Commentary
Patient safety 2.0: slaying dragons, not just investigating them.
Citation Text:
Card AJ. Patient safety 2.0: slaying dragons, not just investigating them. J Patient Saf. 2023;19(6):394-395. doi:10.1097/pts.0000000000001140.
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psnet.ahrq.gov/issue/identification-and-prevention-common-adverse-drug-events-intensive-care-unit
December 16, 2020 - Special or Theme Issue
Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit.
Citation Text:
Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit. Papadopoulos J, Kane-Gill SL, Cooper B, eds. Crit Care Med. 2010;38:(s…
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psnet.ahrq.gov/issue/selecting-safe-and-easier-use-products-healthcare-using-human-factors-specification-and
February 21, 2018 - Book/Report
Selecting Safe and Easier to Use Products for Healthcare Using Human Factors Specification and Checklists.
Citation Text:
Selecting Safe and Easier to Use Products for Healthcare Using Human Factors Specification and Checklists. Buckinghamshire, UK. Clinical Human Facto…
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psnet.ahrq.gov/issue/nursing-peer-review-developing-framework-patient-safety
January 15, 2020 - Commentary
Nursing peer review: developing a framework for patient safety.
Citation Text:
Diaz L. Nursing peer review: developing a framework for patient safety. J Nurs Adm. 2008;38(11):475-9. doi:10.1097/01.NNA.0000339473.27349.28.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb5.html
February 01, 2023 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Appendix B8: Unsafe Behavior Worksheet
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Table of Contents
The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Chapter 1. Introduction and Program Overview …
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hcup-us.ahrq.gov/
September 01, 2025 - What is HCUP?
The
Healthcare Cost and Utilization Project (HCUP) includes the
largest collection of longitudinal hospital care data in the
United States.
Overview of HCUP
Online HCUP
Overview Course is an interactive course that provides
information a…
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www.ahrq.gov/prevention/guidelines/archive.html
July 01, 2018 - Clinical Practice Guidelines Archive
The National Guideline Clearinghouse™ taken down on July 16, 2018, because federal funding though AHRQ was no longer available to support them. Please visit AHRQ's Guidelines and Measures (GAM) microsite to find information about its legacy guidelines and measures cleari…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/043-ss-training-preop-nasal-mupirocin.pptx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
AHRQ Safety Program for MRSA Prevention: Targeting SSI
Preoperative Surgical Decolonization
Staff Training: Nasal Decolonization in the Preoperative Area
Nasal Mupirocin Ointment
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Su…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/047-ss-faqs-staff-safety-side-effects.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Preoperative Decolonization
Staff – Frequently Asked Questions:
Safety and Side Effects
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
The products we are recommending for surgical site infection (SSI) preven…
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hcup-us.ahrq.gov/home.jsp
September 01, 2025 - What is HCUP?
The
Healthcare Cost and Utilization Project (HCUP) includes the
largest collection of longitudinal hospital care data in the
United States.
Overview of HCUP
Online HCUP
Overview Course is an interactive course that provides
information a…
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www.ahrq.gov/talkingquality/plan/manage.html
November 01, 2018 - How Will You Manage a Health Care Quality Reporting Project?
Managing a quality reporting project requires forethought, patience, and creativity. While detailed advice on how to manage this kind of effort is beyond the scope of TalkingQuality, this page offers some basic guidance to help you keep your project…
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psnet.ahrq.gov/issue/prospective-error-recording-surgery-analysis-1108-elective-neurosurgical-cases
January 22, 2016 - Study
Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases.
Citation Text:
Stone S, Bernstein M. Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. Neurosurgery. 2007;60(6):1075-80; discussion 1080-2.
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www.ahrq.gov/patient-safety/resources/simulation-issue-brief4.html
July 01, 2024 - Simulation To Improve Patient Safety: Getting Started
Use Simulation To Adopt and Adapt Best Practices
Previous Page Next Page
Table of Contents
Simulation To Improve Patient Safety: Getting Started
Introduction
Leverage Patient Safety Infrastructure
Use Simulation To Adopt and Adapt Best Prac…
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psnet.ahrq.gov/issue/common-formats-patient-safety-data-collection
October 08, 2024 - Press Release/Announcement
Common Formats for Patient Safety Data Collection.
Citation Text:
Common Formats for Patient Safety Data Collection. Agency for Healthcare Research and Quality. Fed Register. Mar 6, 2024;89(45);15992.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool5_portfolio_des.pptx
June 02, 2025 - Tool 5: Portfolio Design
Tool 5: Portfolio Design
Brief Description: A PowerPoint deck that includes examples of readmission reduction portfolios that can be modified to develop the data-informed, multifaceted “portfolio” of readmission reduction efforts in your hospital.
Purpose: To facilitate the formulation of you…