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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45160/psn-pdf
    May 18, 2016 - Clues to better health care from old malpractice lawsuits. May 18, 2016 Landro L. https://psnet.ahrq.gov/issue/clues-better-health-care-old-malpractice-lawsuits Closed claims have been considered a source for adverse event data for years, and recently such data has been utilized to inform safety improvement work. …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46199/psn-pdf
    September 27, 2017 - The development and implementation of checklists in obstetrics. September 27, 2017 Medicine S for M-F, Bernstein PS, Combs A, et al. The development and implementation of checklists in obstetrics. Am J Obstet Gynecol. 2017;217(2):B2-B6. doi:10.1016/j.ajog.2017.05.032. https://psnet.ahrq.gov/issue/development-and-i…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46736/psn-pdf
    December 17, 2018 - Back to basics: the Universal Protocol. December 17, 2018 Spruce L. Back to Basics: The Universal Protocol: 1.4 www.aornjournal.org/content/cme. AORN J. 2018;107(1):116-125. doi:10.1002/aorn.12002. https://psnet.ahrq.gov/issue/back-basics-universal-protocol Wrong-site, wrong-procedure, and wrong-patient errors are…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42965/psn-pdf
    April 20, 2014 - Development of a Web-based surgical booking and informed consent system to reduce the potential for error and improve communication. April 20, 2014 Siracuse JJ, Benoit E, Burke J, et al. Development of a Web-based surgical booking and informed consent system to reduce the potential for error and improve communicat…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44048/psn-pdf
    November 20, 2015 - Clinical handover of the critically ill postoperative patient: an integrative review. November 20, 2015 Gardiner TM, Marshall AP, Gillespie BM. Clinical handover of the critically ill postoperative patient: an integrative review. Aust Crit Care. 2015;28(4):226-34. doi:10.1016/j.aucc.2015.02.001. https://psnet.ahrq…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35786/psn-pdf
    May 07, 2007 - When Things Go Wrong: Responding to Adverse Events. May 7, 2007 Boston, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2006. https://psnet.ahrq.gov/issue/when-things-go-wrong-responding-adverse-events This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk manage…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862151/psn-pdf
    February 07, 2024 - Taking up the challenge to improve name and role recognition in the operating room. February 7, 2024 Thota B, Rabinowitz A, Guttman OT. Taking up the challenge to improve name and role recognition in the operating room. J Patient Saf. 2024;20(1):45-47. doi:10.1097/pts.0000000000001177. https://psnet.ahrq.gov/issue…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45198/psn-pdf
    January 23, 2017 - Investigating teamwork in the operating room: engaging stakeholders and setting the agenda. January 23, 2017 Frasier LL, Quamme SRP, Becker A, et al. Investigating Teamwork in the Operating Room: Engaging Stakeholders and Setting the Agenda. JAMA Surg. 2017;152(1):109-111. doi:10.1001/jamasurg.2016.3110. https://…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44224/psn-pdf
    June 10, 2015 - To be sued less, doctors should consider talking to patients more. June 10, 2015 Carroll AE. https://psnet.ahrq.gov/issue/be-sued-less-doctors-should-consider-talking-patients-more Reporting on trends associated with medical malpractice, how the same physicians tend to get sued, and reasons patients file claims, …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41534/psn-pdf
    July 25, 2012 - Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care. July 25, 2012 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;256(2):203-10. doi:10.1097/SLA.0b013e…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73668/psn-pdf
    September 01, 2021 - Leadership: an effective human factor during COVID-19. September 1, 2021 Dhahri AA, Refson J. Leadership: an effective human factor during COVID-19. BMJ Leader. 2021;5:203- 205. doi:10.1136/leader-2020-000384. https://psnet.ahrq.gov/issue/leadership-effective-human-factor-during-covid-19 Hierarchy and professional…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38177/psn-pdf
    March 02, 2011 - Violations of behavioral practices revealed in closed claims reviews. March 2, 2011 Griffen FD, Stephens LS, Alexander JB, et al. Violations of behavioral practices revealed in closed claims reviews. Ann Surg. 2008;248(3):468-474. doi:10.1097/sla.0b013e318185e196. https://psnet.ahrq.gov/issue/violations-behavioral…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45070/psn-pdf
    October 03, 2017 - When There's Harm in the Hospital: Can Transparency Replace "Deny and Defend"? October 3, 2017 National Health Policy Forum. Washington, DC: George Washington University. March 11, 2016. https://psnet.ahrq.gov/issue/when-theres-harm-hospital-can-transparency-replace-deny-and-defend This report provides the insight…

  14. Monitoring and Modifying the Plan: Huddle | Agency for Healthcare Research and Quality

    www.ahrq.gov/teamstepps-program/curriculum/team/tools/huddle.html
    May 01, 2023 - Monitoring and Modifying the Plan: Huddle The Huddle is a tool for communicating adjustments to a care plan that is already in place. When a plan is or has to be altered due to changes in the patient’s condition or team membership, or the current plan is not working, either the designated leader or a situatio…

  15. Login

    integrationacademy.ahrq.gov/lam/templates/selfService/selfServiceLogin.php?scope=user&name=onc-self-service
    Login Welcome to ONC password reset self service. This is a government website, only authorized personnel are allowed access.  Please enter your user name and password. User name Password Login Forgot password? HHS System Login This warning banner provides privacy and securit…

  16. TeamSTEPPS Tools | Agency for Healthcare Research and Quality

    www.ahrq.gov/teamstepps-program/resources/modules/index.html
    February 01, 2024 - TeamSTEPPS Tools Browse the tools used in the TeamSTEPPS training modules: Module 1: Explanation of Communication Concepts and Tools SBAR Closed-Loop Communication Call-Out Check-Back (or Repeat-Back) Teach-Back Handoff I-PASS ANTICipate SHARQ Module 1 Training Slides (PPTX, 4.1 MB) …

  17. The Fluidity of Diagnostic "Wet Reads" | PSNet

    psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
    April 24, 2018 - The Fluidity of Diagnostic "Wet Reads" Citation Text: Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 …

  18. Diagnostic Safety Centers of Excellence | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/diagnostic-excellence-grants/index.html
    February 01, 2025 - Diagnostic Safety Centers of Excellence In fiscal year 2022, Congress authorized funding to support AHRQ's research to address failures in the diagnostic process, which may include the establishment of Research Centers of Diagnostic Excellence to develop systems, measures, and new technology solutions to improv…

  19. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/assess-psc-hsop-facguide.docx
    January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle Slide Title and Commentary Slide Number and Slide Title Slide Assess Patient Safety Culture Using the Hospital Survey on Patient Safety SAY: In this module, we will introduce the Hospital Survey on Patient Safety, or HSOPS, and review why it is important, as wel…

  20. Presentation: Program Overview

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/assess-psc-hsop-slides.pptx
    January 01, 2017 - Presentation: Program Overview Assess Patient Safety Culture Using the Hospital Survey on Patient Safety AHRQ Safety Program for Mechanically Ventilated Patients AHRQ Pub. No. 16(17)-0018-30-EF January 2017 Using HSOPS ‹#› AHRQ Safety Program for Mechanically Ventilated Patients 1 Learning Objectives After t…
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