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psnet.ahrq.gov/issue/sorry-works
November 15, 2024 - Multi-use Website
Sorry Works!
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March 17, 2011
Sorry Works! supports a full-disclosure approach to medical errors. They encourage…
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www.ahrq.gov/nursing-home/materials/leadership/index.html
June 01, 2022 - Leadership, Management, and Quality Improvement
Nursing home administrators and others may benefit from the following specific resources that address leadership and quality improvement.
Leadership and Management
Leading By Example Learning Module
This learning module offers ideas to help boost mora…
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www.ahrq.gov/nursing-home/learning-modules/support.html
December 01, 2022 - Emotional and Organizational Support for Staff series
This series of three learning modules features strategies to help nursing home teams recognize and manage stress, work together to tackle common challenges, and practice open communication.
Module 1: Identifying & Overcoming Anxiety
We all experience st…
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www.ahrq.gov/topics/transitions-care.html
Transitions of Care
AHRQ's tools and research to ensure safe and seamless transitions of patients from one care setting to another, reducing preventable adverse events, drug-related errors, and other problems.
Tools TeamSTEPPS Module on Communication
Toolkit to Engage High-Risk P…
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effectivehealthcare.ahrq.gov/sites/default/files/communicating_risk_media_wilkes.ppt
April 01, 2006 - THIS IS OUR TEACHER!
Communicating the Harms and Benefits of Medical Treatments: a look from both sides of the aisle…
Prepared by michael wilkes and richard kravitz
We learn about medicine through the media
Press coverage is too often inaccurate, superficial, or sensationalized.
Some of the most import…
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psnet.ahrq.gov/node/60746/psn-pdf
July 29, 2020 - Misdiagnosis of a Pelvic Mass versus Pregnancy
July 29, 2020
Leiserowitz GS, Herding H. Misdiagnosis of a Pelvic Mass versus Pregnancy. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy
The Case
A 28-year-old woman arrived at the Emergency Department (ED) complaining o…
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psnet.ahrq.gov/node/49802/psn-pdf
August 01, 2017 - Add-on Case and the Missing Checklist
August 1, 2017
Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
The Case
A 65-year-old woman was admitted for evaluation of abdominal pain and weight loss. Based on diagnostic
data and ima…
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psnet.ahrq.gov/node/61080/psn-pdf
October 28, 2020 - Preventing Complications during Aneurysm Clipping –
the Role of Neuromonitoring.
October 28, 2020
DeLemos C. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring
…
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psnet.ahrq.gov/node/33630/psn-pdf
March 01, 2006 - Team Training: Classroom Training vs. High-Fidelity
Simulation
March 1, 2006
Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulation. PSNet [internet].
2006.
https://psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
Point–Counterpoint
Editor's Note…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/partnering-executive-facilitator-guide.docx
June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use
1
Partnering With a Senior Executive
Long-Term Care
Slide Title and Commentary
Slide Number and Slide
Partnering With a Senior Executive
Long-Term Care
SAY:
Thank you for joining us. This presentation is titled “Partnering With a Senior Executive.” This is our f…
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-learning-benchmarks.pdf
June 02, 2025 - TeamSTEPPS Learning Benchmarks
TeamSTEPPS Learning Benchmarks
Instructions: These questions focus on medical teamwork and communication and their effect
on quality and safety in patient care. For each of the following questions, please circle the
letter next to the one best answer.
1. A nurse is called t…
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psnet.ahrq.gov/primer/electronic-health-records
March 15, 2025 - Electronic Health Records
Citation Text:
Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
June 16, 2021 - Looking for Meds in All the Wrong Places
Citation Text:
Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XML…
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cdsic.ahrq.gov/sites/default/files/2025-09/Final%20508_Measuring%20Patient%20Experience%20of%20PC%20CDS_0.pdf
January 01, 2025 - Measuring Patient Experience of Patient-Centered Clinical Decision Support
Stakeholder Center:
Measuring Patient Experience of
Patient-Centered Clinical
Decision Support
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
www.ahrq.gov
Contract No: 75Q80120D00018
Prepared by:
M…
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psnet.ahrq.gov/issue/how-surgical-trainees-handle-catastrophic-errors-qualitative-study
March 19, 2019 - Study
How surgical trainees handle catastrophic errors: a qualitative study.
Citation Text:
Balogun JA, Bramall AN, Bernstein M. How Surgical Trainees Handle Catastrophic Errors: A Qualitative Study. J Surg Educ. 2015;72(6):1179-84. doi:10.1016/j.jsurg.2015.05.003.
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Fo…
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psnet.ahrq.gov/issue/physicians-and-electronic-health-records-statewide-survey
December 31, 2014 - Study
Physicians and electronic health records: a statewide survey.
Citation Text:
Simon SR, Kaushal R, Cleary PD, et al. Physicians and electronic health records: a statewide survey. Arch Intern Med. 2007;167(5):507-12.
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Format:
Google Scholar PubMed BibTeX …
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psnet.ahrq.gov/issue/safeguarding-patients-complexity-science-high-reliability-organizations-and-implications-team
March 31, 2021 - Commentary
Safeguarding patients: complexity science, high reliability organizations, and implications for team training in healthcare.
Citation Text:
McKeon LM, Oswaks JD, Cunningham PD. Safeguarding patients: complexity science, high reliability organizations, and implications for te…
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psnet.ahrq.gov/issue/association-between-organizational-culture-and-ability-benefit-just-culture-training
August 04, 2021 - Study
The association between organizational culture and the ability to benefit from "just culture" training.
Citation Text:
David DS. The Association Between Organizational Culture and the Ability to Benefit From "Just Culture" Training. J Patient Saf. 2019;15(1):e3-e7. doi:10.1097/PTS.…
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psnet.ahrq.gov/issue/medical-error-care-unrepresented-disclosure-and-apology-vulnerable-patient-population
March 13, 2024 - Commentary
Medical error in the care of the unrepresented: disclosure and apology for a vulnerable patient population.
Citation Text:
Byju AS, Mayo K. Medical error in the care of the unrepresented: disclosure and apology for a vulnerable patient population. J Med Ethics. 2019;45(12):821…
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psnet.ahrq.gov/issue/improving-teamwork-general-medical-units-when-teams-do-not-work-face-face
June 12, 2013 - Study
Improving teamwork on general medical units: when teams do not work face-to-face.
Citation Text:
McComb SA, Henneman EA, Hinchey KT, et al. Improving teamwork on general medical units: when teams do not work face-to-face. Jt Comm J Qual Patient Saf. 2012;38(10):471-478.
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