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www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Ruddick_61.pdf
March 09, 2008 - Using Root Cause Analysis to Reduce Falls in Rural Health Care Facilities
Using Root Cause Analysis to Reduce Falls
in Rural Health Care Facilities
Patricia Ruddick, RN, MSN; Karen Hannah, MBA; Charles P. Schade, MD; Gail Bellamy, PhD;
John Brehm, MD; David Lomely, BA.
Abstract
Prevention of patient falls i…
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hcup-us.ahrq.gov/datainnovations/clinicaldata/AdvisoryCouncilmeeting12032009_rev.pdf
December 31, 2007 - The health information infrastructure in America today . . . .
Agency for Health Care Administration
Florida Center for Health Information and Policy Analysis
AHRQ Pilot Project:
Adding Clinical Data Elements
to Administrative Data
Christopher B. Sullivan, Ph.D.
Bahia Diefenbach, Ph.D.
Florida Agency for He…
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - SPOTLIGHT CASE
A Weighty Mistake
Citation Text:
Bokser SJ. A Weighty Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/node/33583/psn-pdf
March 01, 2023 - Simulation Training
March 1, 2023
Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/simulation-training
Originally published in 2014 by researchers at the University of California, San Francisco. Updated in
March 2023, by Jennifer J. Edwards, MS, RN, CHSE…
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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - SPOTLIGHT CASE
Out of Sight, Out of Mind: Out-of-Office Test Result Management
Citation Text:
Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
…
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psnet.ahrq.gov/node/865455/psn-pdf
March 27, 2024 - Communication During Transitions of Care
March 27, 2024
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/communication-during-transitions-care
Introduction
Inaccurate or untimely communication and ineffective teamwork in healthca…
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs024090-turchin-final-report-2019.pdf
January 01, 2019 - Identification of Patients with Low Life Expectancy - Final Report
FINAL PROGRESS REPORT
Identification of Patients with Low Life Expectancy
Principal Investigator
Alexander Turchin, MD, MS1,2
Team M…
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psnet.ahrq.gov/web-mm/novel-drug-misuse
September 30, 2010 - SPOTLIGHT CASE
Novel Drug Misuse
Citation Text:
Angus DC, Milbrandt EB. Novel Drug Misuse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
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psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md
February 26, 2025 - In Conversation With…Christine A. Sinsky, MD
February 1, 2016
Citation Text:
In Conversation With…Christine A. Sinsky, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
April 01, 2008 - Anticoagulation: Held Too Long
Citation Text:
Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
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psnet.ahrq.gov/node/49651/psn-pdf
May 01, 2012 - The Perils of Cross Coverage
May 1, 2012
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/perils-cross-coverage
Case Objectives
Explain the recently instituted ACGME duty hour regulations for 2011 as they pertain to handoffs and
care transitions.
Describe ed…
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psnet.ahrq.gov/node/33785/psn-pdf
May 01, 2015 - In Conversation With… John D. Birkmeyer, MD
May 1, 2015
In Conversation With… John D. Birkmeyer, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md
Editor's note: John D. Birkmeyer, MD, is an internationally recognized health services researcher with
expertise in perfo…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/diagnostic-safety-resources.pdf
May 01, 2023 - Diagnostic Safety Resource List
Improving Diagnostic Safety in Medical Offices:
A Resource List for Users of the AHRQ Diagnostic
Safety Supplemental Item Set
I. Purpose
This document provides a list of references to websites and other publicly available resources that
medical offices can use to improve the ex…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
June 02, 2025 - SAY:
The Patient and Family Engagement module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit focuses on an important topic: Making sure patients and their family members understand what is happening during the patient’s hospital stay, are active participants in the patient’s care, and are prepared for…
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psnet.ahrq.gov/node/49858/psn-pdf
April 01, 2019 - What Happened on Telemetry?
April 1, 2019
Sandau KE, Funk M. What Happened on Telemetry? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/what-happened-telemetry
Case Objectives
Describe current hospital practices for continuous telemetry monitoring.
Appreciate key recommendations from the Update to Practice…
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www.ahrq.gov/patient-safety/settings/hospital/vtguide/appb2.html
January 01, 2020 - Preventing Hospital-Associated Venous Thromboembolism
Appendix B: Risk Assessment Models, Protocols, and Order Sets (continued)
Previous Page Next Page
Table of Contents
Preventing Hospital-Associated Venous Thromboembolism
Preface
Executive Summary
Chapter 1. The Framework for Improvement
C…
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psnet.ahrq.gov/node/49478/psn-pdf
April 01, 2005 - Compare and Contrast
April 1, 2005
Cho KC, Chertow GM. Compare and Contrast. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/compare-and-contrast
Case Objectives
Define contrast nephropathy (CN)
List risk factors for CN
Implement pharmacologic strategies for CN prophylaxis
Follow an algorithm for CN risk …
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight06.html
January 01, 2014 - How are CHIPRA quality demonstration States working together to improve the quality of health care for children?
Evaluation Highlight No. 6
Authors: Dana Petersen, Henry Ireys, Grace Ferry, and Leslie Foster
Contents
Key Messages
Background
Findings
Conclusion
Implications
Learn More
Endno…
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www.ahrq.gov/evidencenow/projects/state/how-to-guide/guide5.html
August 01, 2024 - Developing and Sustaining State-Based Infrastructure To Support Primary Care Quality Improvement
5. Moving Toward Sustainability
Previous Page Next Page
Table of Contents
Developing and Sustaining State-Based Infrastructure To Support Primary Care Quality Improvement
Using This Guide
1. Backgrou…
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …