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  1. 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…
  2. 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…
  3. 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…
  4. 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…
  5. Psn-Pdf (pdf file)

    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 …
  6. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…
  7. Psn-Pdf (pdf file)

    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…
  8. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  9. Psn-Pdf (pdf file)

    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…
  10. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
  11. 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…
  12. 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. Copy Citation Format: Google Scholar BibTeX EndNote …
  13. 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…
  14. Slide 1 (ppt file)

    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…
  15. 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, …
  16. psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
    September 23, 2024 - Rescue Improvement Conference Innovation Summary Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL July 23, 2024 View more articles from the same authors. Innovation Contact …
  17. 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…
  18. 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…
  19. 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 …
  20. 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…