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4161. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49501/psn-pdf
      February 03, 2006 - Lost in Transition February 1, 2006 Beach C. Lost in Transition. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/lost-transition Case Objectives Provide an overview of transitions in continuously operating industries Review cognitive error Describe the complex dynamics of transitions in emergency care Pro…

4162. Facilitator-Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module3/facilitator-notes.docx
      March 01, 2017 - Facilitator Notes SAY: The Staff Empowerment module will discuss the importance of staff empowerment and strategies for implementing staff empowerment in your facility. SLIDE 1 SAY: The objectives are to— · Cite staff empowerment concepts · Discuss how staff empowerment contributes to a culture of resident safe…

4163. Incorporating Patient Preferences in Patient-Centered Clinical Decision Support (pdf file)
      cdsic.ahrq.gov/sites/default/files/2025-06/TPC%20Topic%20Highlight%20Patient%20Preferences.pdf
      January 01, 2025 - Incorporating Patient Preferences in Patient-Centered Clinical Decision Support AHRQ Pub. No. 25-0055 June 2025 Incorporating Patient Preferences in Patient-Centered Clinical Decision Support Patient preferences can support a patient’s care experience and healthcare decision making. This resource shows differe…

4164. Patient and Family Engagement in Long Term Care | PSNet
      psnet.ahrq.gov/curated-library/patient-and-family-engagement-long-term-care
      April 10, 2024 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Patient and Family Engagement in Long Term Care  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, C…

4165. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/866984
      January 01, 2020 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Interdisciplinary teamwork Curated Library Foundations Medical teamwork and the evolution of safety science: a critical review. Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22:13-27. In this narrative review, the authors contr…

4166. Guide to Sustaining a Program To Reduce Catheter-Associated Urinary Tract Infections in Long-Term Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/sustainability/sustaining-guide.pdf
      March 01, 2017 - Guide to Sustaining a Program To Reduce Catheter-Associated Urinary Tract Infections in Long-Term Care AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Guide to Sustaining a Program To Reduce Catheter-Associated Urinary Tract Infections in Long-Term Care AHRQ Public…

4167. Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Deis_82.pdf
      June 03, 2008 - Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement Jamie N. Deis, MD; Keegan M. Smith, MD; Michael D. Warren, MD; Patricia G. Throop, BSN, CPHQ; Gerald B. Hickson, MD; …

4168. 2014 CAHPS Clinician & Group Survey Database Chartbook (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2014_cg_cahps_chartbook.pdf
      January 01, 2014 - 2014 CAHPS Clinician & Group Survey Database Chartbook THE CAHPS DATABASE 2014 CAHPS Clinician & Group Survey Database 2014 Chartbook: What Patients Say About Their Health Care Providers and Medical Practices AHRQ Contract No.: HHSA290201300003C Managed and prepared by: Westat, Rockville, MD …

4169. Mechanisms of communicating health information through Facebook: implications for consumer health information technology design. | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/informing-consumer-health-information-technology-design-how-patients-use-social/citation/mechanisms
      January 01, 2023 - Mechanisms of communicating health information through Facebook: implications for consumer health information technology design. Citation Menefee HK, Thompson MJ, Guterbock TM, et al. Mechanisms of communicating health information through Facebook: implications for consumer health information technolo…

4170. A novel health information technology communication system to increase caregiver activation in the context of hospital-based pediatric hematopoietic cell transplantation: a pilot study. | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/personalized-engagement-tool-pediatric-bmt-patients-and-caregivers/citation/novel
      January 01, 2023 - A novel health information technology communication system to increase caregiver activation in the context of hospital-based pediatric hematopoietic cell transplantation: a pilot study. Citation Maher M, Hanauer DA, Kaziunas E, et al. A novel health information technology communication system to incr…

4171. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72831/psn-pdf
      March 10, 2021 - Enhancing a culture of safety through disclosure of adverse events. March 10, 2021 Cornelissen C, Call RC, Harbell MW, et al. APSF Newsletter. February 202136(1);25-27 https://psnet.ahrq.gov/issue/enhancing-culture-safety-through-disclosure-adverse-events Error disclosure is supported by a robust safety …

4172. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44789/psn-pdf
      April 25, 2016 - Guideline for prevention of retained surgical items. April 25, 2016 Putnam K. Guideline for prevention of retained surgical items. AORN J. 2015;102(6):P11-P13. https://psnet.ahrq.gov/issue/guideline-prevention-retained-surgical-items Retained surgical items are considered a sentinel event in perioperative care. Thi…

4173. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46334/psn-pdf
      August 09, 2017 - Maternal deaths at MetroWest hospital prompt state probes. August 9, 2017 Kowalczyk L. Boston Globe. July 29, 2017. https://psnet.ahrq.gov/issue/maternal-deaths-metrowest-hospital-prompt-state-probes Maternal death is a sentinel event. This news article reports on two incidents at one hospital that prompted inves…

4174. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38708/psn-pdf
      April 30, 2014 - Frequency and clinical importance of pages sent to the wrong physician. April 30, 2014 Wong BM, Quan S, Cheung M, et al. Frequency and clinical importance of pages sent to the wrong physician. Arch Intern Med. 2009;169(11):1072-3. doi:10.1001/archinternmed.2009.117. https://psnet.ahrq.gov/issue/frequency-and-clini…

4175. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/847734/psn-pdf
      April 19, 2023 - Patient safety tools for primary care. April 19, 2023 Domdera J. Fam Pract Manag. 2023;30(2):24-28. https://psnet.ahrq.gov/issue/patient-safety-tools-primary-care A large segment of patients receives outpatient care. This commentary suggests that high-reliability concepts be applied in the primary care environment…

4176. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44526/psn-pdf
      October 07, 2015 - The evolution of a safety culture. October 7, 2015 Patton BS, Donovan KJ. The Evolution of a Safety Culture. Air Med J. 2015;34(5):264-8. doi:10.1016/j.amj.2015.05.012. https://psnet.ahrq.gov/issue/evolution-safety-culture This commentary describes how an air transport unit at one hospital developed a safety cultu…

4177. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841199/psn-pdf
      December 07, 2022 - Press Play on Safety Conversations. December 7, 2022 Healthcare Excellence Canada. 2022. https://psnet.ahrq.gov/issue/press-play-safety-conversations After a patient safety incident, effective discussions are critical for healing and improvement. This website houses collections of materials to support constructive…

4178. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73078/psn-pdf
      September 19, 2024 - Risky Business: Creating Connections. July 17, 2024 Joseph B. Martin Conference Center, Boston, MA; September 19, 2024. https://psnet.ahrq.gov/issue/risky-business-creating-connections A core tenant of the patient safety improvement drawing from the experiences of various high-risk industries to address system saf…

4179. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45261/psn-pdf
      June 22, 2016 - Hospitals that mess up are urged to confess. June 22, 2016 Tozzi J. Bloomberg News Service. June 10, 2016. https://psnet.ahrq.gov/issue/hospitals-mess-are-urged-confess The concept of proactively responding to medical mistakes through disclosure and compensation has gained acceptance in recent years. This news art…

4180. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41048/psn-pdf
      November 04, 2012 - An educational intervention to increase "speaking-up" behaviors in nurses and improve patient safety. November 4, 2012 Sayre MM, McNeese-Smith D, Leach LS, et al. An educational intervention to increase "speaking-up" behaviors in nurses and improve patient safety. J Nurs Care Qual. 2012;27(2):154-60. doi:10.1097/N…