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psnet.ahrq.gov/node/36909/psn-pdf
January 05, 2017 - Medical team training: applying crew resource
management in the Veterans Health Administration.
January 5, 2017
Dunn EJ, Mills PD, Neily J, et al. Medical team training: applying crew resource management in the
Veterans Health Administration. Jt Comm J Qual Patient Saf. 2007;33(6):317-325.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/42357/psn-pdf
December 04, 2016 - Disclosing medical mistakes: a communication
management plan for physicians.
December 4, 2016
Petronio S, Torke A, Bosslet G, et al. Disclosing medical mistakes: a communication management plan for
physicians. Perm J. 2013;17(2):73-9. doi:10.7812/TPP/12-106.
https://psnet.ahrq.gov/issue/disclosing-medical-mistakes…
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psnet.ahrq.gov/node/39982/psn-pdf
January 17, 2012 - Hand-off Communications.
January 17, 2012
DeRosier JM, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the VA
National Center for Patient Safety's prospective risk analysis system.
https://psnet.ahrq.gov/issue/hand-communications
The Joint Commission Center for Transforming Hea…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/nft-state-simulation.xlsx
June 02, 2025 - Child HCAHPS NFT State Simulation
census division
Table 1 Mean, Standard Deviation (SD), Range of Hospital-Level Top Scores by Census Division in Child HCAHPS National Field Test
Census Division Census division 1 Census division 2 Census division 3 Census division 4 Census division 5 Census division 6 Census divisio…
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psnet.ahrq.gov/node/837658/psn-pdf
July 08, 2022 - Preventable Transfer to the Hospital
July 8, 2022
Agrawal G, Kashkouli P, Bakerjian D. Preventable Transfer to the Hospital. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/preventable-transfer-hospital
The Case
A 78-year-old veteran with dementia-associated aggressive behavior and multiple comorbidities had…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/2016/2016_hospitalsops_report_pt1.pdf
January 01, 2016 - Communicate and discuss the survey results.
3. Develop focused action plans.
4. … Communicate action plans and deliverables.
5. Implement action plans.
6. … Communicate and discuss survey results.
3. Develop focused action plans.
4. … Communicate action plans and deliverables.
5. Implement action plans.
6. … Step 4: Communicate Action Plans and Deliverables
After you develop your action plans, you need to communicate
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psnet.ahrq.gov/web-mm/preventable-transfer-hospital
March 31, 2022 - Preventable Transfer to the Hospital
Citation Text:
Agrawal G, Kashkouli P, Bakerjian D. Preventable Transfer to the Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
Copy Citation
Format:
Google Scholar Bi…
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psnet.ahrq.gov/node/49654/psn-pdf
June 01, 2012 - Transfer Troubles
June 1, 2012
Hains IM. Transfer Troubles. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfer-troubles
Case Objectives
Recognize that transfer of patients between hospitals is common.
Understand the frequency of errors and adverse events in the transfer of patients between hospitals.
…
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psnet.ahrq.gov/node/73642/psn-pdf
August 25, 2021 - Sudden Collapse During Upper Gastrointestinal
Endoscopy: Expect the Unexpected
August 25, 2021
Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-
unexpected
…
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www.ahrq.gov/sites/default/files/2024-01/arora-report.pdf
January 01, 2024 - Final Progress Report: Development and Validation of a Tool to Evaluate Handoff Quality
Final Progress Report
1. Title Page
Title: Development and Validation of a Tool to Evaluate Handoff Quality
Principal Investigator and Team Members:
Vineet Arora, MD, MAPP (Principal Investigator); Jeanne Farnan, MD, MHPE (Co…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/132-gap-analysis-hospital-level.pdf
April 01, 2025 - Hospital-Level Gap Analysis for MRSA and SSI Prevention
AHRQ Safety Program for MRSA
Prevention: Targeting SSI
Hospital-Level Gap Analysis for
MRSA and SSI Prevention
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal F…
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psnet.ahrq.gov/node/42276/psn-pdf
May 15, 2013 - Kadcyla (ado-trastuzumab emtansine): drug safety
communication—potential medication errors resulting
from name confusion.
May 15, 2013
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; May 6, 2013.
https://psnet.ahrq.gov/issue/kadcyla-ado-trastuzumab-emtansine-drug-safety-communication-pot…
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psnet.ahrq.gov/node/43591/psn-pdf
August 02, 2015 - The automated operating room: a team approach to
patient safety and communication.
August 2, 2015
Nissan J, Campos V, Delgado H, et al. The automated operating room: a team approach to patient safety
and communication. JAMA Surg. 2014;149(11):1209-10. doi:10.1001/jamasurg.2014.1825.
https://psnet.ahrq.gov/issue/au…
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psnet.ahrq.gov/node/39915/psn-pdf
December 18, 2014 - Improving the quality of discharge communication with
an educational intervention.
December 18, 2014
Key-Solle M, Paulk E, Bradford K, et al. Improving the quality of discharge communication with an
educational intervention. Pediatrics. 2010;126(4):734-9. doi:10.1542/peds.2010-0884.
https://psnet.ahrq.gov/issue/im…
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digital.ahrq.gov/ahrq-funded-projects/using-innovative-communication-technology-improve-health-young-african-american/final-report
January 01, 2023 - Communication-Focused Technologies for Improving the Health of Young African-American Women - Final Report
Citation
Jack B, Bickmore T, Cuoco M, et al. Communication-Focused Technologies for Improving the Health of Young African-American Women - Final Report. (Prepared by Boston University under Contr…
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs022087-singh-final-report-2018.pdf
January 01, 2018 - portals offered an alternative communication channel
when barriers were encountered attempting to communicate
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medical-office-diagnostic-safety-database-report-2024.pdf
January 01, 2024 - share their concerns about a patient’s
health condition; providers document differential diagnoses,
communicate
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www.ahrq.gov/hai/cauti-tools/phys-championsgd/appa.html
October 01, 2015 - Resident Physicians as Champions in Preventing Device-Associated Infections
Appendix A. Teamwork and Communication Definitions and Tools
Previous Page
Table of Contents
Resident Physicians as Champions in Preventing Device-Associated Infections
Preamble and Summary
Epidemiology of Invasive Dev…
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psnet.ahrq.gov/node/44766/psn-pdf
January 23, 2017 - Why do we still page each other? Examining the
frequency, types and senders of pages in academic
medical services.
January 23, 2017
Carlile N, Rhatigan JJ, Bates DW. Why do we still page each other? Examining the frequency, types and
senders of pages in academic medical services. BMJ Qual Saf. 2017;26(1):24-29. do…
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psnet.ahrq.gov/issue/advancing-effective-communication-cultural-competence-and-patient-and-family-centered-care
September 21, 2011 - Book/Report
Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals.
Citation Text:
Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. Oakbrook Terrace, IL:…