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psnet.ahrq.gov/issue/potential-medication-overdose-enfit-low-dose-tip-syringe-fda-safety-communication
October 28, 2020 - Press Release/Announcement
Potential for medication overdose with ENFit low dose tip syringe: FDA Safety Communication.
Citation Text:
Potential for medication overdose with ENFit low dose tip syringe: FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug A…
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psnet.ahrq.gov/issue/impact-teamwork-improvement-training-communication-and-teamwork-climate-ambulatory
October 28, 2020 - Study
Impact of teamwork improvement training on communication and teamwork climate in ambulatory reproductive health care.
Citation Text:
Dodge LE, Nippita S, Hacker MR, et al. Impact of teamwork improvement training on communication and teamwork climate in ambulatory reproductive healt…
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psnet.ahrq.gov/issue/development-and-validation-tool-assess-emergency-physicians-nontechnical-skills
December 12, 2012 - Study
Development and validation of a tool to assess emergency physicians' nontechnical skills.
Citation Text:
Flowerdew L, Brown R, Vincent CA, et al. Development and validation of a tool to assess emergency physicians' nontechnical skills. Ann Emerg Med. 2012;59(5):376-385.e4. doi:10…
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psnet.ahrq.gov/issue/improving-communication-between-teams-managing-boarded-patients-surgical-specialty-ward
September 29, 2017 - Commentary
Improving the communication between teams managing boarded patients on a surgical specialty ward.
Citation Text:
Puvaneswaralingam S, Ross D. Improving the communication between teams managing boarded patients on a surgical specialty ward. BMJ Qual Improv Rep. 2016;5(1). doi:1…
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psnet.ahrq.gov/issue/role-information-technology-healthcare-communications-efficiency-and-patient-safety
October 19, 2022 - Commentary
The role of information technology in healthcare communications, efficiency, and patient safety: application and results.
Citation Text:
Prince SB, Herrin DM. The role of information technology in healthcare communications, efficiency, and patient safety: application and res…
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psnet.ahrq.gov/issue/kaiser-permanentes-performance-improvement-system-part-4-creating-learning-organization
July 19, 2023 - Commentary
Kaiser Permanente's performance improvement system, part 4: creating a learning organization.
Citation Text:
Schilling L, Dearing JW, Staley P, et al. Kaiser Permanente's performance improvement system, Part 4: Creating a learning organization. Jt Comm J Qual Patient Saf. 2011…
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psnet.ahrq.gov/issue/student-observed-surgical-safety-practices-across-urban-regional-health-authority
August 12, 2020 - Study
Student-observed surgical safety practices across an urban regional health authority.
Citation Text:
Spence J, Goodwin B, Enns C, et al. Student-observed surgical safety practices across an urban regional health authority. BMJ Qual Saf. 2011;20(7):580-6. doi:10.1136/bmjqs.2010.04…
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psnet.ahrq.gov/issue/protecting-patients-unsafe-system-etiology-and-recovery-intraoperative-deviations-care
October 19, 2012 - Study
Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.
Citation Text:
Hu Y-Y, Arriaga AF, Roth EM, et al. Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care. Ann Surg. 2012;…
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psnet.ahrq.gov/issue/speaking-across-drapes-communication-strategies-anesthesiologists-and-obstetricians-during
May 08, 2017 - Study
Speaking across the drapes: communication strategies of anesthesiologists and obstetricians during a simulated maternal crisis.
Citation Text:
Minehart RD, Pian-Smith MCM, Walzer TB, et al. Speaking across the drapes: communication strategies of anesthesiologists and obstetrician…
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psnet.ahrq.gov/issue/covid-19-can-last-several-months-diseases-long-haulers-have-endured-relentless-waves
April 03, 2005 - Newspaper/Magazine Article
COVID-19 can last for several months. The disease’s “long-haulers” have endured relentless waves of debilitating symptoms—and disbelief from doctors and friends.
Citation Text:
Young E. COVID-19 can last for several months. The disease’s “long-haulers” have end…
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psnet.ahrq.gov/issue/implementation-modified-bedside-handoff-postpartum-unit
November 16, 2022 - Commentary
Implementation of a modified bedside handoff for a postpartum unit.
Citation Text:
Wollenhaup CA, Stevenson EL, Thompson J, et al. Implementation of a Modified Bedside Handoff for a Postpartum Unit. J Nurs Admin. 2017;47(6):320-326. doi:10.1097/NNA.0000000000000487.
Copy Cit…
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psnet.ahrq.gov/issue/surgical-procedure-grid-safety-and-operating-room-communication-multisite-surgery
June 17, 2014 - Commentary
A surgical procedure grid for safety and operating room communication in multisite surgery.
Citation Text:
Insalaco LF, Spiegel JH. A Surgical Procedure Grid for Safety and Operating Room Communication in Multisite Surgery. JAMA Facial Plast Surg. 2018;20(3):185-186. doi:10.10…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module3/guide.docx
March 01, 2017 - AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Long-Term Care Safety Modules
Module 3: Staff Empowerment
Material Use Guide
Learning Objectives:
· Cite staff empowerment concepts
· Discuss how staff empowerment contributes to a culture of resident safety, leading to improved outcomes and quality of life
· Illus…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/davis-p-et-al-2001
January 01, 2001 - Davis P et al. 2001 "An evaluation of telehealth in the provision of rheumatologic consults to a remote area."
Reference
Davis P, Howard R, Brockway P. An evaluation of telehealth in the provision of rheumatologic consults to a remote area. J Rheumatol 2001;28(8):1910-1913.
Abstract
"Objective…
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psnet.ahrq.gov/node/840173/psn-pdf
November 16, 2022 - Catching those who fall through the cracks: integrating a
follow-up process for emergency department patients
with incidental radiologic findings.
November 16, 2022
Barrett TW, Garland NM, Freeman CL, et al. Ann Emerg Med. 2022;80(3):235-242.
https://psnet.ahrq.gov/innovation/catching-those-who-fall-thr…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/webinar-012220-fry.pdf
June 02, 2025 - Understanding CAHPS® Surveys: A Primer for New Users - Fry
WHAT IS PATIENT EXPERIENCE
AND HOW DOES CAHPS
MEASURE IT?
Stephanie Fry
Senior Study Director
Westat
What is Patient Experience?
Patient experience encompasses the range of interactions that
patients have with the health care system, including:
Co…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/keydriver-vtcollaborative.pdf
January 24, 2018 - PQMP National Asthma Quality Metric Key Driver Diagram (Vermont)
PQMP National Asthma Quality Metric Key Driver Diagram (Vermont) – (I)Prevention/(II)Acute Episode/ (III)ED Care
Global Aim:
We aim to test and
implement national
performance
measures that
accurately assesses
components of
quality care for
c…
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www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-slides.html
December 01, 2017 - The Science of Improving Patient Safety and Identifying Defects: Slide Presentation
AHRQ Safety Program for Surgery
Slide 1: AHRQ Safety Program for Surgery—Onboarding
The Science of Improving Patient Safety and Identifying Defects
Slide 2: Learning Objectives
After this session, you will be able to…
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module4-presenters-notes.pdf
January 05, 2022 - TeamSTEPPS® Diagnosis Improvement: Module 4 Leadership - Facilitator’s Notes
Slide 1
TeamSTEPPS® for Diagnosis
Improvement
…
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psnet.ahrq.gov/node/49497/psn-pdf
December 01, 2005 - One
should endeavor to develop an implementation plan that is “win-win” and communicate that effectively—ie