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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Learning From Defects: Applying the “Swiss cheese model” of System Failure
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
Slide Title and Commentary
Slide Number and Slide
Learning From Defects: Applying the “Swiss C…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/2-why-improve/cahps-section-2-why-improve-patient-experience.pdf
May 01, 2017 - The CAHPS Ambulatory Care Improvement Guide: Why Improve Patient Experience?
The CAHPS Ambulatory Care
Improvement Guide
Practical Strategies for Improving Patient Experience
Section 2: Why Improve Patient Experience?
Visit the AHRQ Website for the full Guide.
May 2017 (updated)
https://www.ahrq.gov/cahps/qua…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety6.html
September 01, 2022 - Reinforcing the Value and Roles of Nurses in Diagnostic Safety: Pragmatic Recommendations for Nurse Leaders and Educators
References
Previous Page Next Page
Table of Contents
Reinforcing the Value and Roles of Nurses in Diagnostic Safety: Pragmatic Recommendations for Nurse Leaders and Educators
I…
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www.ahrq.gov/sites/default/files/wysiwyg/chsp/data/chsp-brief3-variation-in-health-system-characteristics-across-states-2016.pdf
January 01, 2016 - Variation in Health System Characteristics Across States, 2016
1
Variation in Health System
Characteristics Across States, 2016
By the end of 2016, there were 626 health systems* in the United States.
Number of health systems with hospitals located in each State
4 to 7 systems
9 to 15 systems
16 to 22 system…
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psnet.ahrq.gov/node/49808/psn-pdf
October 01, 2017 - High-Risk Medications, High-Risk Transfers
October 1, 2017
Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
The Case
A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …
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psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
April 28, 2021 - Procedural Mishap: Learning Curve?
Citation Text:
Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/840255/psn-pdf
November 16, 2022 - Using Human Factors Engineering and the SEIPS Model
to Advance Patient Safety in Care Transitions
November 16, 2022
Carayon P, Werner N, Makkenchery A, et al. Using Human Factors Engineering and the SEIPS Model to
Advance Patient Safety in Care Transitions . PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspecti…
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psnet.ahrq.gov/web-mm/patient-mix
December 01, 2007 - Patient Mix-Up
Citation Text:
Shojania KG. Patient Mix-Up. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - The Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
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psnet.ahrq.gov/web-mm/flying-object-hits-mri
September 01, 2005 - Flying Object Hits MRI
Citation Text:
Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet
April 01, 2008 - Patient Safety and the Evolution of WebM&M and PSNet
September 1, 2019
View more articles from the same authors.
Citation Text:
Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. Rockville (MD): Agency for Healthcare Resea…
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psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
June 01, 2014 - Mixup Beyond the Medication Label
Citation Text:
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
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digital.ahrq.gov/ahrq-funded-projects/assess-risk-wrong-patient-errors-emr-allows-multiple-records-open
January 01, 2023 - Assess Risk of Wrong-Patient Errors in an EMR That Allows Multiple Records Open
Project Final Report ( PDF , 451.19 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily re…
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digital.ahrq.gov/sites/default/files/docs/page/Grannis.ppt
January 01, 2004 - Slide 1
Patient Matching in the Indiana Network for Patient Care
Shaun Grannis, M.D. M.S.
The Regenstrief Institute and
Indiana University School of Medicine
Regenstrief Beginnings
Endowed by Sam Regenstrief - inventor of the low cost dishwasher
Obsessed with process improvement
Supported the creation of the…
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psnet.ahrq.gov/periodic-issue/periodic-issue-473
March 25, 2025 - March 5, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - Rescue Improvement Conference Innovation Summary
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July 23, 2024
View more articles from the same authors.
Innovation
Contact
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integrationacademy.ahrq.gov/sites/default/files/2025-05/AHRQ-Integration-Academy-Overview.pdf
January 01, 2025 - The Academy for Integrating Behavioral Health and Primary Care
The Academy for Integrating Behavioral
Health and Primary Care
https://integrationacademy.ahrq.gov/
https://integrationacademy.ahrq.gov/
What is integrated behavioral health?
• A practice team of primary care and
behavioral health clinicians workin…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-276-ocd-executive-summary.pdf
December 01, 2024 - Executive summary_Comparative Effectiveness Review No. 276: Diagnosis and Management of Obsessive Compulsive Disorders in Children
Comparative Effectiveness Review
Number 276
Diagnosis and Management of Obsessive
Compulsive Disorders in Children
Executive Summary
Main Points
• Diagnosis of O…
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digital.ahrq.gov/ahrq-funded-projects/information-needs-homecare-nurses-during-admission-and-care-planning
January 01, 2023 - Information Needs of Homecare Nurses During Admission and Care Planning
Project Final Report ( PDF , 471.08 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent …
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digital.ahrq.gov/ahrq-funded-projects/improving-guideline-development-and-implementation
January 01, 2023 - Improving Guideline Development and Implementation
Project Description
Annual Summaries
Publications
Project Details -
Completed
Contract Number
07-587F-07, 08-587F-07, 09-587F-07, 10-587F-07
Funding Mechanism(s)
Inter-Agenc…