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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38544/psn-pdf
    September 02, 2009 - A pilot study examining undesirable events among emergency department–boarded patients awaiting inpatient beds. September 2, 2009 Liu SW, Thomas SH, Gordon JA, et al. A pilot study examining undesirable events among emergency department-boarded patients awaiting inpatient beds. Ann Emerg Med. 2009;54(3):381-5. do…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47583/psn-pdf
    December 05, 2018 - Interpersonal and organizational dynamics are key drivers of failure to rescue. December 5, 2018 Smith ME, Wells EE, Friese CR, et al. Interpersonal And Organizational Dynamics Are Key Drivers Of Failure To Rescue. Health Aff (Millwood). 2018;37(11):1870-1876. doi:10.1377/hlthaff.2018.0704. https://psnet.ahrq.gov/…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852278/psn-pdf
    August 09, 2023 - Identifying failure modes in telemedicine: an instructional needs assessment. August 9, 2023 Monkman H, Kuziemsky C, Homco J, et al. Identifying failure modes in telemedicine: an instructional needs assessment. Stud Health Technol Inform. 2023;304:39-43. doi:10.3233/shti230365. https://psnet.ahrq.gov/issue/identif…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46663/psn-pdf
    November 29, 2017 - ISMP survey shows provider text messaging often runs afoul of patient safety. November 29, 2017 ISMP Medication Safety Alert! Acute Care Edition. November 16, 2017;22:1-5. https://psnet.ahrq.gov/issue/ismp-survey-shows-provider-text-messaging-often-runs-afoul-patient-safety Texting medication orders is convenient …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45506/psn-pdf
    November 30, 2016 - Is an indication-based prescribing system in our future? November 30, 2016 ISMP Medication Safety Alert! Acute Care Edition. November 17, 2016;21:1-5. https://psnet.ahrq.gov/issue/indication-based-prescribing-system-our-future Health information technology has enhanced prescribers' ability to document the purpose o…

  6. Measuring and Responding to Safety Culture Across Healthcare | Agency for Healthcare Research and Quality

    www.ahrq.gov/action-alliance/webinars/measuring-safety-culture.html
    May 01, 2025 - Measuring and Responding to Safety Culture Across Healthcare This webinar was the third of a three-part series on Safety Culture in Healthcare. On April 15, 2025, presenters discussed how to measure and improve safety culture using tools like AHRQ’s Surveys on Patient Safety Culture® (SOPS®) Program, the Safety…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46611/psn-pdf
    January 01, 2021 - Sustaining teamwork behaviors through reinforcement of TeamSTEPPS principles. November 15, 2017 Lee S-H, Khanuja HS, Blanding RJ, et al. Sustaining Teamwork Behaviors Through Reinforcement of TeamSTEPPS Principles. J Patient Saf. 2021;17(7):e582-e586. doi:10.1097/pts.0000000000000414. https://psnet.ahrq.gov/issue/…

  8. Implementing Self-Measured Blood Pressure in Primary Care Practices | Agency for Healthcare Research and Quality

    www.ahrq.gov/evidencenow/tools/implementing-smbp.html
    August 01, 2023 - Implementing Self-Measured Blood Pressure in Primary Care Practices Resource: Implementing SMBP HH4M-Lunch-Learn (4-27-22) (video, 51:18 minutes) In this webinar, American Medical Association (AMA) staff discuss how primary care practices can implement each of the 7 steps for implementing self-measured bl…

  9. Exhibit 6.15. Major Factors that Inhibited Lean Success | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit6-15.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 6.15. Major Factors that Inhibited Lean Success Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Healthcare Cas…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855437/psn-pdf
    November 15, 2023 - Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief. November 15, 2023 National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937. https://psnet.ahrq.gov/issue/advancing-diagnostic-excellence-maternal-h…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42539/psn-pdf
    September 27, 2016 - Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. September 27, 2016 Keers RN, Williams SD, Cooke J, et al. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug Saf. 2013;36(1…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73452/psn-pdf
    June 30, 2021 - Administration of concentrated potassium chloride for injection during a code: still deadly! June 30, 2021 ISMP Medication Safety Alert! Acute care edition. June 3, 2021; 26(11): 1-5. https://psnet.ahrq.gov/issue/administration-concentrated-potassium-chloride-injection-during-code-still- deadly Concentrated …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853436/psn-pdf
    September 13, 2023 - Long-term sustainability and adaptation of I-PASS handovers. September 13, 2023 Ryan SL, Logan M, Liu X, et al. Long-term sustainability and adaptation of I-PASS handovers. Jt Comm J Qual Patient Saf. 2023;19(12):689-697. doi:10.1016/j.jcjq.2023.07.007. https://psnet.ahrq.gov/issue/long-term-sustainability-and-ada…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852286/psn-pdf
    August 09, 2023 - Guidelines on Human Factors in Critical Situations 2023. August 9, 2023 Bijok B, Jaulin F, Picard J, et al. Guidelines on human factors in critical situations 2023. Anaesth Crit Care Pain Med. 2023;42(4):101262. doi:10.1016/j.accpm.2023.101262. https://psnet.ahrq.gov/issue/guidelines-human-factors-critical-situatio…

  15. Apply CUSP | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cusp/modules/apply/index.html
    July 01, 2018 - Apply CUSP The Apply CUSP module of the CUSP Toolkit introduces Just Culture principles, which emphasize shared accountability and attitudes towards risk. This module also summarizes the concepts and activities of the other six modules in the CUSP Toolkit, including TeamSTEPPS communication tools. This module…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73365/psn-pdf
    June 09, 2021 - Enhancing psychological safety in mental health services. June 9, 2021 Hunt DF, Bailey J, Lennox BR, et al. Enhancing psychological safety in mental health services. Int J Ment Health Syst. 2021;15(1):33. doi:10.1186/s13033-021-00439-1. https://psnet.ahrq.gov/issue/enhancing-psychological-safety-mental-health-servi…

  17. CAHPS Health Plan Survey 5.0 Measures | Agency for Healthcare Research and Quality

    www.ahrq.gov/cahps/surveys-guidance/hp/about/survey-measures.html
    September 01, 2020 - CAHPS Health Plan Survey 5.0 Measures For more information: Patient Experience Measures from the CAHPS Health Plan Survey (PDF, 308 KB) Getting Needed Care Q9          Easy for respondent to get necessary care, tests, or treatment Q18        Respondent got appointment with specialists as soon as needed …

  18. 2019 CAHPS Health Plan Survey Database Chartbook Executive Summary (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2019_hpchartbook_infographic.pdf
    January 01, 2019 - 2019 CAHPS Health Plan Survey Database Chartbook Executive Summary CAHPS® 2019 Health Plan Survey Database This overview of resu lts summarizes how health plan enrollees across all populations rate their health plan based on the 2019 Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Health Plan S…

  19. Surveys on Patient Safety Culture Action Planning Steps (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/action-planning-tool-infographic-sops.pdf
    March 01, 2024 - Surveys on Patient Safety Culture Action Planning Steps ACTION PLANNING FOR THE SOPS SURVEYS The AHRQ Surveys on Patient Safety Culture® (SOPS®) Action Planning Tool consists of a three-step process to guide teams as they work to improve patient safety culture. 1 Identify Areas To Improve • What areas do you…

  20. CAHPS Outpatient Mental Health Survey Measures | Agency for Healthcare Research and Quality

    www.ahrq.gov/cahps/surveys-guidance/outpatient-mental-health/about/survey-measures.html
    October 01, 2024 - CAHPS Outpatient Mental Health Survey Measures For more information: Patient Experience Measures from the Outpatient Mental Health Survey (PDF, 219 KB) Getting Appointments for Prescription Medicines Q3 Difficulty making appointments for prescription medicine Getting Mental Health Counseling Q10 Difficulty fi…
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