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

    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…
  5. 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. …
  6. Psn-Pdf (pdf file)

    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…
  7. 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…
  8. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…
  9. 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. Copy Citation…
  10. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. 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…
  14. 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…
  15. Psn-Pdf (pdf file)

    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…
  16. 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…
  17. Psn-Pdf (pdf file)

    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 …
  18. 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…
  19. 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…
  20. Psn-Pdf (pdf file)

    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 …