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7001. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35081/psn-pdf
      March 29, 2007 - Achieving Safe and Reliable Healthcare: Strategies and Solutions. March 29, 2007 Leonard MS, Frankel A, Simmonds T, Vega KB. Chicago, IL: Health Administration Press; 2004. https://psnet.ahrq.gov/issue/achieving-safe-and-reliable-healthcare-strategies-and-solutions The authors provide examples of tools and methods…

7002. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40240/psn-pdf
      November 14, 2011 - Quality of Anesthesia Care.  November 14, 2011 Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.   https://psnet.ahrq.gov/issue/quality-anesthesia-care This special issue includes articles discussing safety in anesthesiology practice as well as quality improvement innovations. https://psnet.ahrq.…

7003. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37037/psn-pdf
      September 16, 2011 - Getting beyond blame in your practice. September 16, 2011 Pawar M. Getting beyond blame in your practice. Family Practice Management. 2007;14(5):30-34. https://psnet.ahrq.gov/issue/getting-beyond-blame-your-practice The author discusses how to develop core competencies to help teams create a blame-free culture that…

7004. Collecting Microbiologial Specimens | Agency for Healthcare Research and Quality
      www.ahrq.gov/antibiotic-use/long-term-care/improve/specimens.html
      June 01, 2021 - Collecting Microbiologial Specimens Knowing when to collect a microbiological sample and how to collect good quality samples, are key components to the appropriate diagnosis and, when indicated, treatment of residents with a potential infection. The materials below are primarily intended for nursing staff. …

7005. TeamSTEPPS Research/Evidence Base: Comprehensive Unit-Based Safety Program | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/evidence-base/cusp.html
      May 01, 2023 - TeamSTEPPS Research/Evidence Base: Comprehensive Unit-Based Safety Program Timmel, J., Kent, P. S., Holzmueller, C. G., Paine, L. A., Schulick, R. D., & Pronovost, P. J. (2010). Impact of the comprehensive unit-based safety program (CUSP) on safety culture in a surgical inpatient unit.  Joint Commission Journal…

7006. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36776/psn-pdf
      August 26, 2011 - The role of the chief executive officer in maximizing patient safety. August 26, 2011 Shorr AS. The role of the chief executive officer in maximizing patient safety. Healthcare executive. 2007;22(2):20-2, 24, 26. https://psnet.ahrq.gov/issue/role-chief-executive-officer-maximizing-patient-safety The author discus…

7007. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35781/psn-pdf
      March 15, 2006 - The Josie King Foundation. March 15, 2006 https://psnet.ahrq.gov/issue/josie-king-foundation This foundation was created by the parents of Josie King, a young child who died due to medical error. It supports the Josie King Pediatric Patient Safety Program, which promotes a safety culture at Johns Hopkins Children'…

7008. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36824/psn-pdf
      October 03, 2017 - Department of Defense (DoD) Patient Safety Program. October 3, 2017 US Department of Defense; DOD https://psnet.ahrq.gov/issue/department-defense-dod-patient-safety-program This Web site includes information on several initiatives within the US Military Health System to support its culture of safety and reduce med…

7009. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45424/psn-pdf
      September 21, 2016 - Shift to Safety. September 21, 2016 Canadian Patient Safety Institute. https://psnet.ahrq.gov/issue/shift-safety This initiative facilitates a patient safety approach that focuses on the roles of patients, clinicians, and organizations. The website provides tools and resources to inform and engage individuals as l…

7010. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40491/psn-pdf
      June 08, 2011 - Medical error reduction: the effect of employee satisfaction with organizational support. June 8, 2011 Lee D; Lee SM; Schniederjans MJ. https://psnet.ahrq.gov/issue/medical-error-reduction-effect-employee-satisfaction-organizational-support This survey conducted at four South Korean hospitals found that employees'…

7011. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41441/psn-pdf
      July 08, 2021 - National Diabetes Inpatient Audit -- Harms. July 8, 2021 Leeds, UK: Health and Social Care Information Centre. https://psnet.ahrq.gov/issue/national-diabetes-inpatient-audit-2017 This annual report identified a significant number of medication errors associated with diabetes care in acute hospitals in England and …

7012. Small and Rural and Critical Access Hospitals (Transcript) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/small-hospitals.html
      April 01, 2013 - It does stand for the Comprehensive Unit-based Safety Program, and it’s a cultural intervention to learn

7013. Final Progress Report: Improving Patient Safety by Examining Pathology Errors (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/raab-report.pdf
      January 01, 2025 - implementation strategies in order to identify best implementation practices among sites and site- specific cultural … These errors are compounded by latent problems affecting the cultural focus on production, training issues … Cultural model (top-down versus bottom-up) 9. Punitive history difficult to eradicate 10. … We believe that more study is necessary to better define the cultural barriers to improvement and the

7014. CDS Standards and Regulatory Frameworks Workgroup: An Initial Taxonomy of Override Reasons for PC CDS Recommendations (pdf file)
      cdsic.ahrq.gov/sites/default/files/2024-07/SRF_Taxonomy%20of%20PC%20CDS%20Override%20Recommendations_508_0.pdf
      January 01, 2024 - cancer screening, provided a few additional patient override reasons such as “Cost concerns” and “Cultural … For example, some patients have religious or cultural reasons for not wanting to accept certain services … Subdomain: Patient has a cultural or religious reason for not following the recommendation. … Examples of override reasons from the source reasons related to this subdomain include “Cultural concerns

7015. Synthesizing Lessons Learned Using Health Information Technology - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r03hs018830-nemeth-final-report-2013.pdf
      January 01, 2013 - Synthesizing Lessons Learned Using Health Information Technology - Final Report Grant Final Report Grant ID: R03HS018830 Synthesizing Lessons Learned Using Health Information Technology Inclusive Project Dates: 05/01/10 – 04/30/13 Principal Investigator: Lynne S. Nemeth, PhD, RN Tea…

7016. Chapter 2. Determining Surgical Site Infection Rates | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ssi/ssi2.html
      April 01, 2018 - Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection Chapter 2. Determining Surgical Site Infection Rates Previous Page Next Page Table of Contents Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection Executive Summary C…

7017. Statistical Brief #137: Treatment of Sore Throats: Antibiotic Prescriptions and Throat Cultures for Children under 18 Years of Age, 2002–2004 (Average Annual) (pdf file)
      meps.ahrq.gov/data_files/publications/st137/stat137.pdf
      August 01, 2006 - Statistical Brief #137: Treatment of Sore Throats: Antibiotic Prescriptions and Throat Cultures for Children under 18 Years of Age, 2002–2004 (Average Annual) Medical Expenditure Panel Survey Agency for Healthcare Research and Quality STATISTICAL BRIEF #137 August 2006 Treatment of …

7018. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49612/psn-pdf
      November 01, 2010 - Treatment Challenges After Discharge November 1, 2010 Coffey C. Treatment Challenges After Discharge. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge Case Objectives Understand types and frequencies of adverse events occurring between patient discharge from the hospital …

7019. Team-Based Primary Care: Convergence of Improving Engagement, Safety, and Enhanced Joy in Practice (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/teambased-1.pdf
      May 02, 2016 - Team-Based Primary Care: Convergence of Improving Engagement, Safety, and Enhanced Joy in Practice Case Study Problem Addressed A typical primary care visit is not always a satisfying encounter for either the provider or the patient. Providers feel stressed by the need for efficiency and the demands of electronic…

7020. CUSP Toolkit Spread Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/modules/spread/notes.html
      December 01, 2012 - CUSP Toolkit Spread Facilitator Notes CUSP Toolkit The Spread module of the CUSP Toolkit helps an organization share, tailor, and implement the components of a process that have worked well at the unit level. The other CUSP Toolkit modules focus on quality improvement projects at the unit level, where culture…