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psnet.ahrq.gov/node/46270/psn-pdf
April 16, 2018 - Impact of a restraint management bundle on restraint use
in an intensive care unit.
April 16, 2018
Hall DK, Zimbro KS, Maduro RS, et al. Impact of a Restraint Management Bundle on Restraint Use in an
Intensive Care Unit. J Nurs Care Qual. 2018;33(2):143-148. doi:10.1097/NCQ.0000000000000273.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/47329/psn-pdf
August 29, 2018 - With scarce access to interpreters, immigrants struggle to
understand doctors' orders.
August 29, 2018
Eldred SM. Health Shots. National Public Radio. August 15, 2018.
https://psnet.ahrq.gov/issue/scarce-access-interpreters-immigrants-struggle-understand-doctors-orders
Using professional interpreters can avert ris…
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psnet.ahrq.gov/node/42922/psn-pdf
April 12, 2014 - Successful implementation of standardized
multidisciplinary bedside rounds, including daily goals, in
a pediatric ICU.
April 12, 2014
Seigel J, Whalen L, Burgess E, et al. Successful implementation of standardized multidisciplinary bedside
rounds, including daily goals, in a pediatric ICU. Jt Comm J Qual Patient S…
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psnet.ahrq.gov/node/837976/psn-pdf
August 31, 2022 - Does seasonal variation in orthopaedic trauma volume
correlate with adverse hospital events and burnout?
August 31, 2022
Waldron J, Denisiuk M, Sharma R, et al. Does seasonal variation in orthopaedic trauma volume correlate
with adverse hospital events and burnout? Injury. 2022;53(6):2053-2059. doi:10.1016/j.injury…
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/action-alliance-agenda-040323_LOCKED.pdf
April 25, 2023 - The National Action Alliance to Advance Patient Safety
Summer Webinar Series
Tuesday, April 25, 2023
2:00 – 3:00 PM ET
2:00 PM Welcome, Call to Action and Overview of the National Action Alliance
Robert Otto Valdez, Ph.D., M.H.S.A.
Director
Agency for Healthcare Research and Quality
Helen Haske…
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hcup-us.ahrq.gov/reports/factsandfigures/2009/pdfs/FF_2009_section1.pdf
January 01, 2009 - HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2009 10
SECTION 1 OVERVIEW STATISTICS FOR INPATIENT HOSPITAL STAYS
EXHIBIT 1.1 Characteristics of U.S. Community Hospitals ............................................................... 11
EXHIBIT 1.2 Inpatient Hospital…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-medication-safety.pdf
April 30, 2025 - ■ Another project improved warfarin management among residents in 26 community nursing homes
representative … Residents experienced less constant pain but reported the same
pain intensity. … compared with non-Hispanic White
residents (from 23.2% to 16.8%). … Another study looked at residents of
15 Veterans Affairs Community Living Centers age 65 and over with … Nearly 52 percent of the
696 residents were prescribed one or more medications that could exacerbate
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psnet.ahrq.gov/node/33685/psn-pdf
May 01, 2009 - The newer generation of residents, they're used to this, so
they would expect it.
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - do interruptions, instructions, and experience affect the diagnostic accuracy and response time of residents
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-research-report-unhealthy-alcohol-use-final.pdf
September 01, 2018 - and
continuous QI; a strong multidisciplinary team; and, an organized plan for training faculty and
residents … history of
practice
innovation and
continuous QI
culture
Organized plan
for training
faculty and
residents
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psnet.ahrq.gov/node/866400/psn-pdf
January 01, 2025 - Medication administration in aged care facilities: a mixed-
methods systematic review.
July 31, 2024
Garratt S, Dowling A, Manias E. Medication administration in aged care facilities: a mixed?methods
systematic review. J Adv Nurs. 2025;81(2):621-640. doi:10.1111/jan.16318.
https://psnet.ahrq.gov/issue/medication-a…
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psnet.ahrq.gov/node/864380/psn-pdf
March 13, 2024 - Stepped-wedge cluster RCT to assess the effects of an
electronic medication system on medication
administration errors.
March 13, 2024
Westbrook JI, Li L, Woods AL, et al. Stepped-wedge cluster RCT to assess the effects of an electronic
medication system on medication administration errors. Stud Health Technol Inf…
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psnet.ahrq.gov/node/37294/psn-pdf
May 21, 2013 - Improving Hand-Off Communication.
May 21, 2013
Oakbrook Terrace lL: Joint Commission Resources; 2007. ISBN 9781599400907.
https://psnet.ahrq.gov/issue/improving-hand-communication
The process of transferring primary responsibility for patient care is commonly referred to as a handoff.
Handoffs are inherently dange…
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psnet.ahrq.gov/node/60846/psn-pdf
January 01, 2021 - Safety climate associated with adverse events in nursing
homes: a national VA study.
August 26, 2020
Quach ED, Kazis LE, Zhao S, et al. Safety climate associated with adverse events in nursing homes: a
national VA study. J Am Med Dir Assoc. 2021;22(2):388-392. doi:10.1016/j.jamda.2020.05.028.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/41688/psn-pdf
April 17, 2013 - Teaching hospital financial status and patient outcomes
following ACGME duty hour reform.
April 17, 2013
Navathe AS, Silber JH, Small DS, et al. Teaching hospital financial status and patient outcomes following
ACGME duty hour reform. Health Serv Res. 2013;48(2 Pt 1):476-98. doi:10.1111/j.1475-
6773.2012.01453.x.
…
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psnet.ahrq.gov/node/73570/psn-pdf
January 01, 2022 - Long-term care nurses' experiences with patient safety
incident management: a qualitative study.
August 4, 2021
Serre N, Espin S, Indar A, et al. Long-term care nurses' experiences with patient safety incident
management: a qualitative study. J Nurs Care Qual. 2022;37(2):188-194.
doi:10.1097/ncq.0000000000000583.
…
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psnet.ahrq.gov/node/866586/psn-pdf
August 28, 2024 - Hidden flaws behind expert-level accuracy of multimodal
GPT-4 vision in medicine.
August 28, 2024
Jin Q, Chen F, Zhou Y, et al. Hidden flaws behind expert-level accuracy of multimodal GPT-4 vision in
medicine. NPJ Dig Med. 2024;7(1):190. doi:10.1038/s41746-024-01185-7.
https://psnet.ahrq.gov/issue/hidden-flaws-beh…
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psnet.ahrq.gov/node/60583/psn-pdf
June 10, 2020 - Containing COVID-19 in the emergency department: the
role of improved case detection and segregation of
suspect cases.
June 10, 2020
Wee LE, Fua T?P, Chua YY, et al. Containing COVID-19 in the emergency department: the role of
improved case detection and segregation of suspect cases. Acad Emerg Med. 2020;27(5):379…
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psnet.ahrq.gov/node/837058/psn-pdf
May 11, 2022 - Establishing psychological safety in clinical supervision:
multi-professional perspectives.
May 11, 2022
Lee EH, Pitts S, Pignataro S, et al. Establishing psychological safety in clinical supervision: multi?
professional perspectives. Clin Teach. 2022;19(2):71-78. doi:10.1111/tct.13451.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/45396/psn-pdf
August 10, 2016 - Examining the July Effect: a national survey of academic
leaders in medicine.
August 10, 2016
Levy K, Voit J, Gupta A, et al. Examining the July Effect: A National Survey of Academic Leaders in
Medicine. Am J Med. 2016;129(7):754.e1-5. doi:10.1016/j.amjmed.2016.05.001.
https://psnet.ahrq.gov/issue/examining-july-e…