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psnet.ahrq.gov/node/836850/psn-pdf
March 31, 2022 - Annual Perspective: Topics in Medication Safety
March 31, 2022
Harris IB, Dowell P, Mossburg SE. Annual Perspective: Topics in Medication Safety. PSNet [internet].
2022.
https://psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
Introduction
Issues with medication management and errors in medi…
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psnet.ahrq.gov/node/851971/psn-pdf
July 31, 2023 - Failure to Adhere to Dietary Restrictions Leading to
Complications and Poor Follow-up
July 31, 2023
Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications
and poor follow-up. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/failure-adhere-dietary-restricti…
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - SPOTLIGHT CASE
Spotlight: Mistaken Attribution, Diagnostic Misstep
Citation Text:
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citat…
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digital.ahrq.gov/sites/default/files/docs/citation/r36hs022201-yuan-final-report-2015.pdf
January 01, 2015 - Understanding How Social Influence and Social Networks Affect Electronic Medical Record Implementation - Final Report
1
Understanding how social influence and social networks influence EMR implementation
Principal Investigator: Christina T. Yuan, MPH
Research Team: Ingrid M. Nembhard, Ph.D. (Dissertation Co…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/atypical-antipsychotics-off-label-update_research-protocol.pdf
May 19, 2010 - Evidence Report on the
Source: www.effectivehealthcare.ahrq.gov
Published Online: May 19, 2010
Evidence-based Practice Center Systematic Review Protocol
Project Title: Efficacy and Comparative Effectiveness of Off-Label Use of Atypical
Antipsychotics – Update
I. Background and Objectives for the Sys…
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effectivehealthcare.ahrq.gov/sites/default/files/suppl-2-user-guide-to-ocer_130129.pdf
January 01, 2011 - 177
Abstract
This supplement describes how counterfactual theory is used to define causal effects and the conditions
in which observed data can be used to estimate counterfactual-based causal effects. Basic definitions
and language used in causal graph theory are then presented. The graphical separation rules linki…
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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - SPOTLIGHT CASE
Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery
Citation Text:
Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd
November 01, 2017 - In Conversation With… Wanda Pratt, PhD
November 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Wanda Pratt, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Cop…
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www.ahrq.gov/sites/default/files/2024-09/segall-report.pdf
January 01, 2024 - Final Progress Report: Workload effects on response time to life-threatening arrhythmias
Workload effects on response time to life-threatening arrhythmias
Principal investigator: Noa Segall, PhD
Team members: Christopher Granger, MD
Melanie Wright, PhD
Gene Hobbs, CHT
Alberto Bonifacio, RN, BSN, MHA, CEN
Jeffr…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight11.pdf
September 08, 2015 - How are CHIPRA quality demonstration States using quality reports to drive heatlh care improvements for children? Evaluation Highlight No. 11
The CHIPRA Quality
Demonstration Grant Program
In February 2010, the Centers for Medicare &
Medicaid Services (CMS) awarded 10 grants,
funding 18 States, to improve the qu…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/lessons/lessons-performance-comparisons.pdf
October 01, 2019 - Lessons from the Field: Making Performance Comparisons
Lessons from the Field: Making Performance
Comparisons
Prepared for the Agency for Healthcare Research and Quality by L&M
Policy Research, LLC with guidance from the Pediatric Quality Measure
Program (PQMP) Grantees
i
Table of Contents
List o…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-7.html
March 01, 2022 - Improving Education—A Key to Better Diagnostic Outcomes
References
Previous Page
Table of Contents
Improving Education—A Key to Better Diagnostic Outcomes
Introduction
Foundations of Diagnosis Education
Current State of Diagnosis Education
Competencies To Improve Diagnosis in Health Profes…
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www.ahrq.gov/ncepcr/tools/case-studies/health-team-works.html
August 01, 2014 - Case Studies of Exemplary Primary Care Practice Facilitation Training Programs
Training Program Summary: HealthTeamWorks’ Coach University
Previous Page Next Page
Table of Contents
Case Studies of Exemplary Primary Care Practice Facilitation Training Programs
Overview
Training Program Summary: H…
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
January 01, 2024 - Spotlight
Hindsight is 20/20: Thrombolytics for Alcohol
Intoxication
Source and Credits
• This presentation is based on the April 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Eric Signoff, MD, Noelle Boctor, MD, and David K.
B…
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www.ahrq.gov/sites/default/files/2024-11/blumenthal-report.pdf
January 01, 2024 - Final Progress Report: Validation of an Innovative Approach to Error Reduction
Final Progress Report
Validation of an Innovative Approach To Error Reduction
Principal Investigator: David Blumenthal, MD, MPP
Team Members:
Carlos A. Camargo, Jr., MD, DrPH (Massachusetts General Hospital)
Paul D. Cleary, PhD (Yale…
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www.ahrq.gov/sites/default/files/2024-10/sirio2-report.pdf
January 01, 2024 - Final Progress Report: Systems Approach for Improving Region-Wide Patient Safety
FINAL PROGRESS REPORT
Systems Approach for Improving Region-Wide Patient Safety
Carl A. Sirio, MD (Principal Investigator)
Rober Weber, RPh
Carlene Muto, MD
Donna Keyser, PhD
Jan Pringle, PhD
Rangaraj Ramanujam, PhD
John Jernig…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/learn/faclearncusp.docx
January 01, 2009 - SAY:
The “Learn About CUSP” module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit introduces CUSP and provides an overview of resources to use when applying the CUSP model.
Slide 1
SAY:
This module offers an outline and brief history of the CUSP model, summarizes the CUSP Toolkit modules, and expl…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
December 01, 2017 - Accessible Facilitator Guide: Learn From Defects for Sustainability
Slide Title and Commentary
Slide Number and Slide
Sustainability: Learning From Defects
SAY:
This module will review some concepts from Learning From Defects Through Sensemaking. It will also cover the Learning From Defects process from the per…
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www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
December 01, 2017 - Sustainability: Learning From Defects: Facilitator Notes
AHRQ Safety Program for Surgery
Slide 1: Sustainability: Learning From Defects
Say:
This module will review some concepts from Learning From Defects Through Sensemaking. It will also cover the Learning From Defects process from the perspective of …
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_6-coaching.pptx
July 01, 2023 - PowerPoint Presentation
Coaching
Module 6 of 8
SPPC-II
Toolkit
AHRQ Pub. No. 23-0046
July 2023
Hospital AIM Team
Leads
SPPC-II
SCRIPT
Welcome to Module 6 of the SPPC-II Teamwork Toolkit. In this module, we’ll learn some tactics for coaching your frontline providers on using the teamwork tools.
1
Coaching
Involve…