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8321. Slide 1
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/leveraging-cultural-change-080814.pptx
      January 01, 2013 - Slide 1 Leveraging Cultural Change to Reduce Urinary Catheter Use 1 Linda Greene, RN,MPS,CIC Manager Infection Prevention Highland Hospital Jennifer Tuttle, RN, MSNEd Adult Critical Care Unit Tucson Medical Center Learning Objectives Describe the way in which improvement in the clinical culture can facilitate e…

8322. 130-Ss-Swiss-Cheese-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
      April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI Learning From Defects: Applying the “Swiss cheese model” of System Failure Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries Slide Title and Commentary Slide Number and Slide Learning From Defects: Applying the “Swiss C…

8323. Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates | PSNet
      psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
      October 30, 2024 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL February 9, 2021 …

8324. Chapter 5. Information and Training for Staff, Primary Care Providers, and Residents and their Families | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man5.html
      December 01, 2017 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities Chapter 5. Information and Training for Staff, Primary Care Providers, and Residents and their Families Previous Page Next Page Table of Contents The Falls Management Program: A Quality Improvement Initiative for N…

8325. Ambulatory Safety and Quality Program (2007-2013) | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/past-initiatives/ambulatory-safety-and-quality-program
      January 01, 2023 - Ambulatory Safety and Quality Program (2007-2013) Overview The purpose of the Agency for Healthcare Research and Quality's (AHRQ's) Ambulatory Safety and Quality (ASQ) program is to improve the safety and quality of ambulatory health care in the United States. The program includes four h…

8326. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836791/psn-pdf
      August 21, 2024 - TeamSTEPPS for Diagnosis Improvement. August 21, 2024 TeamSTEPPS for Diagnosis Improvement. https://psnet.ahrq.gov/issue/teamstepps-diagnosis-improvement The recognition of diagnosis as a team activity is energizing new diagnostic process initiatives. Building on the established TeamSTEPPS® principles, this new Te…

8327. Lincoln_p1 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/lincoln_p1.pdf
      January 01, 2010 - Lincoln_p1 Slide 1: Realizing  the Promise of Web 2.0 Marketing  and Dissemination of Patient-­‐Centered  Health Research Jane  Lincoln Project Manager Social Impact -­‐ AARP Slide 2: Untitled http://www.youtube.com/watch?v=h-­‐8PBx7isoM Slide 3:  Realizing  the Promise of Web 2.0 Marketing  and Dis…

8328. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74766/psn-pdf
      June 24, 2024 - Patient handoffs. June 24, 2024 Arora V, Farnan J. UpToDate. June 24, 2024. https://psnet.ahrq.gov/issue/patient-handoffs-0 The change of an inpatient’s location or handoffs between teams can fragment care due to communication, information, and knowledge gaps. This review examines in-patient transition safety issu…

8329. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46039/psn-pdf
      April 05, 2017 - Retained lumbar catheter tip. April 5, 2017 DeLancey JO, Barnard C, Bilimoria KY. Retained Lumbar Catheter Tip. JAMA. 2017;317(12):1269-1270. doi:10.1001/jama.2017.1713. https://psnet.ahrq.gov/issue/retained-lumbar-catheter-tip Retained surgical items are considered a sentinel event. Discussing an incident involvi…

8330. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42403/psn-pdf
      August 02, 2015 - Encouraging patients to ask questions: how to overcome "white-coat silence." August 2, 2015 Judson TJ, Detsky AS, Press MJ. Encouraging patients to ask questions: how to overcome "white-coat silence". JAMA. 2013;309(22):2325-6. doi:10.1001/jama.2013.5797. https://psnet.ahrq.gov/issue/encouraging-patients-ask-quest…

8331. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41634/psn-pdf
      January 31, 2013 - Disclosure of harmful medical errors in out-of-hospital care. January 31, 2013 Lu DW, Guenther E, Wesley AK, et al. Disclosure of harmful medical errors in out-of-hospital care. Ann Emerg Med. 2013;61(2):215-21. doi:10.1016/j.annemergmed.2012.07.004. https://psnet.ahrq.gov/issue/disclosure-harmful-medical-errors-o…

8332. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42874/psn-pdf
      January 29, 2014 - Interdisciplinary Perspectives on Medical Error. January 29, 2014 J Public Health Res. 2013;2:e22-e33. https://psnet.ahrq.gov/issue/interdisciplinary-perspectives-medical-error This special issue explores the challenges of advancing patient safety and highlights the value of interdisciplinary collaboration to achi…

8333. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42158/psn-pdf
      April 03, 2013 - Long-term effects of a perioperative safety checklist from the viewpoint of personnel. April 3, 2013 Böhmer AB, Kindermann P, Schwanke U, et al. Long-term effects of a perioperative safety checklist from the viewpoint of personnel. Acta Anaesthesiol Scand. 2013;57(2):150-7. doi:10.1111/aas.12020. https://psnet.ahr…

8334. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34898/psn-pdf
      April 21, 2011 - Crossing to safety: transforming healthcare organizations for patient safety. April 21, 2011 Ralston JD, Larson EB. Crossing to safety: transforming healthcare organizations for patient safety. J Postgrad Med. 2005;51(1):61-67. https://psnet.ahrq.gov/issue/crossing-safety-transforming-healthcare-organizations-pati…

8335. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40230/psn-pdf
      November 23, 2016 - Talking with Patients and Families about Medical Error: A Guide for Education and Practice. November 23, 2016 Truog RD, Browning DM, Johnson JA, Gallagher TH. Baltimore, MD: Johns Hopkins University Press; 2011. ISBN: 0801898048. https://psnet.ahrq.gov/issue/talking-patients-and-families-about-medical-error-guide-…

8336. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35776/psn-pdf
      March 10, 2011 - A systematic review of the literature on multidisciplinary rounds to design information technology. March 10, 2011 Gurses AP, Xiao Y. A systematic review of the literature on multidisciplinary rounds to design information technology. J Am Med Inform Assoc. 2006;13(3):267-76. https://psnet.ahrq.gov/issue/systematic…

8337. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46490/psn-pdf
      October 29, 2017 - Simulation training in obstetrics. October 29, 2017 Gavin NR, Satin AJ. Simulation Training in Obstetrics. Clin Obstet Gynecol. 2017;60(4):802-810. doi:10.1097/GRF.0000000000000322. https://psnet.ahrq.gov/issue/simulation-training-obstetrics Adverse events in obstetrics put both maternal and infant patients at ris…

8338. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42291/psn-pdf
      September 12, 2016 - Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. September 12, 2016 Acquaviva K, Haskell H, Johnson J. Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. J Prof Nurs. 2013;29(2):95-101. doi:10.1016/j.profnurs.2012.12.009. https://psnet.ahrq.gov/issue/huma…

8339. Text Messaging for Managing Chronic Disease | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/success-stories/text-messaging-managing-chronic-disease
      January 01, 2023 - Text Messaging for Managing Chronic Disease Your browser does not support inline frames. Please go to http://youtu.be/bpP8xawfoi4 to view the video. Principal Investigator: Jennifer Uhrig (Contract No. HHSA290200600001I #7) [5 min., 10 sec.] This project showed that text messaging can effec…

8340. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43017/psn-pdf
      June 12, 2019 - Saying Sorry. June 12, 2019 London, England: NHS Resolution; 2018. https://psnet.ahrq.gov/issue/saying-sorry Although victims of adverse events have clearly expressed their preferences for full error disclosure, most physicians remain uncomfortable with disclosing and apologizing for errors. This leaflet offers in…