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psnet.ahrq.gov/issue/impact-interruptions-duration-nursing-interventions-direct-observation-study-academic
February 13, 2019 - Study
The impact of interruptions on the duration of nursing interventions: a direct observation study in an academic emergency department.
Citation Text:
Cole G, Stefanus D, Gardner H, et al. The impact of interruptions on the duration of nursing interventions: a direct observation stud…
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psnet.ahrq.gov/issue/use-hit-adverse-event-reporting-nursing-homes-barriers-and-facilitators
June 02, 2010 - Study
Use of HIT for adverse event reporting in nursing homes: barriers and facilitators.
Citation Text:
Wagner LM, Castle NG, Handler S. Use of HIT for adverse event reporting in nursing homes: barriers and facilitators. Geriatr Nurs. 2013;34(2):112-5. doi:10.1016/j.gerinurse.2012.10.…
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psnet.ahrq.gov/issue/novel-icu-hand-over-tool-glass-door-patient-room
October 12, 2009 - Commentary
A novel ICU hand-over tool: the glass door of the patient room.
Citation Text:
Wessman BT, Sona C, Schallom M. A Novel ICU Hand-Over Tool: The Glass Door of the Patient Room. J Intensive Care Med. 2017;32(8):514-519. doi:10.1177/0885066616653947.
Copy Citation
Format:
…
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www.ahrq.gov/sites/default/files/2024-12/kmetik-otoole-report.pdf
January 01, 2024 - A third abstraction sample for the HF data was drawn and analyzed to determine
the sensitivity and specificity … endogeneity bias that is inherent in the
empirical question.xvii
Results
Principal Findings
We analyzed
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs025405-schmajuk-final-report-2024.pdf
January 01, 2024 - FG data were analyzed thematically using deductive and inductive techniques; generated themes were
categorized … Interviews lasted between 20 to 45 minutes and were audio-recorded, transcribed verbatim and analyzed
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schyve.pdf
June 02, 2025 - Prologue—Volume 2—Systems Thinking and Patient Safety
1
Prologue
Systems Thinking and Patient Safety
Paul M. Schyve
Patient safety is a prominent theme in health care delivery today. This should
come as no surprise, given that “first, do no harm” has been the ethical watchword
throughout the history of medi…
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www.ahrq.gov/ncepcr/tools/transform-qi/deliver-facilitation/modules/menus.html
February 01, 2022 - Module Menus
The Modules
Introduction to the AHRQ Practice Facilitation Training Modules
Starting with a Practice
Facilitator Fundamentals
Effective Meetings
Introduction to Quality Improvement (QI) in Primary Care
Model for Improvement and PDSA Cycles
Process Mapping
The 5 Whys and Fishbone…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/4-unc-webcast-fenton-wilhelm-amos.pdf
August 15, 2019 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Fenton-Wilhelm-Amos
U
N
C H E A L T H C A R E S Y S T E M
U
N
C H E A L T H C A R E
Culture of Safety Improvement Project
UNC Medical Center
29
U
N
C H …
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www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-slides.html
February 01, 2017 - Learn From Defects in Care of Mechanically Ventilated Patients: Slide Presentation
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients
Learn From Defects in Care of Mechanically Ventilated Patients
Slide 2: Learning Objectives
Af…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
April 01, 2025 - Learning From Defects
Learning From Defects
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
AHRQ Pub. No. 25-0029
April 2025
AHRQ Safety Program for MRSA Prevention: Targeting SSI
AHRQ Safety Program for MRSA Prevention | Surgical Services
Learning From Defects
1
Educat…
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www.ahrq.gov/patient-safety/settings/hospital/resource/guide/web3.html
December 01, 2017 - Webinar 3: Review & Update Readmission Reduction Efforts: Slide Presentation
Designing & Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing Medicaid Readmissions
Text version of Webinar slide presentation.
Slide 1: Designing & Delivering Whole-Person Transitional Care
Designing & …
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/nh/about/measures-nursing-home-family-member-609.pdf
December 28, 2017 - Patient Experience Measures from the CAHPS Nursing Home Family Member Survey
Patient Experience Measures from the CAHPS Nursing Home Family Member Survey
CAHPS® Nursing Home Family Member Survey
Patient Experience Measures from the
CAHPS® Nursing Home Family Member
Survey
Document No. 609
Updated 12/2…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology5.html
April 01, 2025 - Exploration of Foundational Terminology and Paradigms for Improving Diagnosis
Conceptual Paradigms of Diagnostic Quality, Safety, and Excellence
Previous Page Next Page
Table of Contents
Exploration of Foundational Terminology and Paradigms for Improving Diagnosis
Introduction
Perspectives on Di…
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psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
June 24, 2020 - SPOTLIGHT CASE
Fatal Error in Neonate: Does "Just Culture" Provide an Answer?
Citation Text:
Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. …
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psnet.ahrq.gov/node/33638/psn-pdf
August 01, 2006 - Getting Into Patient Safety: A Personal Story
August 1, 2006
Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
Perspective
My journey into patient safety began in 1972. It was born of serendipity enabled by the…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Hundt.pdf
January 01, 2003 - record (discussed
in next section) was collected on all potential participants and will be fully
analyzed … made throughout the interview, as
well as in response to the final open-ended question, are being analyzed … These and all other comments are being content-analyzed and will be
reported at a later date.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/subglottic-litreview.docx
January 01, 2017 - Bibliography
Retrospective Chart Review
(Mareiniss, 2016)5
NEITHER PRO NOR CON: Retrospectively analyzed … Cost Benefit Analysis
(Hallais, 2011)8
PRO: Study in France analyzed the cost benefit of 416 surgical … PRO: Cost/benefit analysis – Study analyzed the cost benefit of 416 surgical patients receiving mechanical
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/dietary-protein-intake-protocol-amendment.pdf
November 28, 2023 - power for
crossover studies
● Other studies with N < 50
participants (for RCTs -
25 participants analyzed … for crossover
studies
● Other studies
with N < 50
participants (for
RCTs - 25
participants
analyzed … participants and
without power for
crossover studies
and N<50
participants (for
RCTs – 25
participants
analyzed
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/prosthesis_research-protocol.pdf
March 16, 2017 - address population characteristics; descriptions of the interventions, exposures, and
comparators analyzed … ; outcome definitions; effect modifiers; enrolled and analyzed
sample sizes; study design features; … Specific methods and metrics (summary measures) to be meta-analyzed will
depend on available, reported
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/skin-cancer_research-protocol.pdf
August 10, 2016 - characteristics, including method of diagnosis; descriptions of the
interventions, exposures, and comparators analyzed … ; outcome definitions; effect
modifiers; enrolled and analyzed sample sizes; study design features; … Specific methods and
metrics (summary measures) to be meta-analyzed will depend on available, reported