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psnet.ahrq.gov/node/74719/psn-pdf
February 02, 2022 - Failure to rescue following emergency surgery: a FRAM
analysis of the management of the deteriorating patient.
February 2, 2022
Sujan M, Bilbro N, Ross A, et al. Failure to rescue following emergency surgery: A FRAM analysis of the
management of the deteriorating patient. Appl Ergon. 2022;98:103608. doi:10.1016/j.a…
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psnet.ahrq.gov/node/837316/psn-pdf
June 01, 2022 - 2022 Updated Results for the AHRQ Surveys on Patient
Safety Culture (SOPS) Diagnostic Safety Supplemental
Items.
June 1, 2022
Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; April
2022. AHRQ Publication No. 22-0027.
https://psnet.ahrq.gov/issue/2022-updated-results-a…
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T2-Sample_Procedures_Phase_3.pdf
May 01, 2014 - Sample Vignettes
Advancing Excellence in Health Care www.ahrq.gov
Agency for Healthcare Research and Quality HAIs
Healthcare-
Associated
Infections
PREVENT
Comprehensive Antibiogram Toolkit: Phase 3
Sample Procedures1
[NURSING HOME NAME]
[DATE]
Purpose and Scope
This procedure covers the use of an antibio…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/best-practices-survey-administration-webcast-intro.pdf
January 24, 2024 - Best Practices for Administering SOPS® Surveys Users (Webcast): Introduction
Best Practices for Administering
SOPS® Surveys
Webcast
January 24, 2024
1:00-2:00 PM ET
Webcast Technical Info
• Audio issues
• Poor Connection
• Use Q&A to submit questions
• Event Website: https://events.westat.com/sops
► Downlo…
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psnet.ahrq.gov/node/47692/psn-pdf
May 29, 2019 - Classifying safety events related to diagnostic imaging
from a safety reporting system using a human factors
framework.
May 29, 2019
Lacson R, Cochon L, Ip I, et al. Classifying Safety Events Related to Diagnostic Imaging From a Safety
Reporting System Using a Human Factors Framework. J Am Coll Radiol. 2019;16(3):…
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psnet.ahrq.gov/node/862601/psn-pdf
February 14, 2024 - Why simulation matters: a systematic review on medical
errors occurring during simulated health care.
February 14, 2024
Bokka L, Ciuffo F, Clapper TC. Why simulation matters: a systematic review on medical errors occurring
during simulated health care. J Patient Saf. 2024;20(2):110-118. doi:10.1097/pts.000000000000…
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psnet.ahrq.gov/node/74054/psn-pdf
November 10, 2021 - Supervision, interprofessional collaboration, and patient
safety in intensive care units during the COVID-19
pandemic.
November 10, 2021
Hennus MP, Young JQ, Hennessy M, et al. Supervision, interprofessional collaboration, and patient safety
in intensive care units during the COVID-19 pandemic. ATS Sch. 2021;2(3):…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2021-childhcahps-infographic.pdf
January 01, 2021 - 2021 CAHPS Child Hospital Survey Database Chartbook Executive Summary
2021 Child Hospital Survey Database
The pilot year 2021 Consumer Assessment of Healthcare
Providers and Systems (CAHPS®) Child Hospital Survey
Database includes 5,858 survey responses voluntarily
submitted by 11 hospitals.
High Scoring
Meas…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2019_cg_cahps_infographic.pdf
January 01, 2019 - 2017 CAHPS Clinician & Group Survey Database Chartbook Executive Summary
CAHPS®
2019 Clinician & Group
Survey Database
How 330,390 patients from 2,002 medical practices
reported 5 measures of patient experience based on the 2019
Consumer Assessment of Healthcare Providers and
Systems (CAHPS®) Clinician & Grou…
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psnet.ahrq.gov/node/840140/psn-pdf
January 01, 2023 - Implementation of the I-PASS handoff program in diverse
clinical environments: a multicenter prospective
effectiveness implementation study.
November 16, 2022
Starmer AJ, Spector ND, O'Toole JK, et al. Implementation of the I?PASS handoff program in diverse
clinical environments: a multicenter prospective effectiv…
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integrationacademy.ahrq.gov/sites/default/files/2020-07/neil_korsen.docx
January 01, 2020 - Translating Research Evidence to Daily Practice for Behavioral Health and Primary Care
Neil Korsen Transcript AHRQ Academy Video
My work for Maine health involves translating research evidence into daily practice. And one of the key things in doing that work is that you have to pay attention to the details and help pe…
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www.ahrq.gov/cpi/about/organization/contacts/key-contacts.html
July 01, 2025 - AHRQ Key Contacts
Offices and Centers Office of the Director Director: Roger D. Klein, M.D., J.D., FCAP Phone: (301) 427-1200 Fax: (301) 427-1201 Email: director@ahrq.hhs.gov Center for Evidence and Practice Improvement Therese Miller, Dr.P.H., Director Phone: (301) 427-1585 Fax: (301) 427-1596 Em…
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digital.ahrq.gov/principal-investigator/aders-deborah
January 01, 2023 - Aders, Deborah
Improving Health Care through Health Information Technology in Morgan County, Indiana - Final Report
Citation
Aders D. Improving Health Care through Health Information Technology in Morgan County, Indiana - Final Report. (Prepared by Morgan Hospital and Medical …
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psnet.ahrq.gov/node/45199/psn-pdf
June 15, 2016 - Towards safer transitions: a curriculum to teach and
assess hospital-to-hospice handoffs.
June 15, 2016
Darrah NJ, O'Connor NR. Toward Safer Transitions: A Curriculum to Teach and Assess Hospital-to-
Hospice Handoffs. J Pain Symptom Manage. 2016;51(6):959-962.e2.
doi:10.1016/j.jpainsymman.2016.01.012.
https://psn…
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psnet.ahrq.gov/node/866106/psn-pdf
June 12, 2024 - Artificial intelligence and healthcare: a journey through
history, present innovations, and future possibilities.
June 12, 2024
Hirani R, Noruzi K, Khuram H, et al. Artificial intelligence and healthcare: a journey through history, present
innovations, and future possibilities. Life (Basel). 2024;14(5):557. doi:10.…
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psnet.ahrq.gov/node/867383/psn-pdf
December 18, 2024 - Interactions between the context of a health-care
organisation and failure: the situational impact of failure
on organisational learning.
December 18, 2024
Horck S. Interactions between the context of a health-care organisation and failure: the situational impact of
failure on organisational learning. Leadership H…
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digital.ahrq.gov/sites/default/files/docs/citation/europe-e-prescribing-report.pdf
February 01, 2011 - education campaigns among prescribers and
patients to inform patients on the benefits e-prescribing and
communicate
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www.ahrq.gov/sites/default/files/2024-02/hoff-report.pdf
January 01, 2024 - Final Progress Report: Creating Learning Cultures Around Mistakes for Residents
1
Project Title: Creating Learning Cultures Around Mistakes for Residents
Timothy J. Hoff, PhD, Principal Investigator
University at Albany, SUNY
School of Public Health
Henry Pohl, MD, Co-Investigator
Joel Bartfield, MD, Co-Investi…
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www.ahrq.gov/sites/default/files/2024-07/buckley-report.pdf
January 01, 2024 - Final Progress Report: Midcoast Maine Patient Safety and IT Integration
Title: Midcoast Maine Patient Safety and IT Integration
Principal Investigator: Maureen Buckle y, PhD, RN – Vice President of Patient
Care
Team Members:
Northeast Health and Partner Organizations
Donna Deblois, MS, RN – Executive Dire…
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www.ahrq.gov/sites/default/files/2025-02/silver-report.pdf
January 01, 2025 - Final Progress Report: Process Reliability and Organizational Learning in Home Health Care
PROL IN HOME HEALTH CARE
Title: Process Reliability and Organizational Learning in Home Health Care
Principal Investigator and Team Members:
Michael P. Silver, MPH Principal Investigator
Cher Edmonds Study Coordinator
Robert…