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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838917/psn-pdf
    October 26, 2022 - The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy. October 26, 2022 Kanter MH, Ghobadi A, Lurvey LD, et al. The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy. Diagnosis (Berl). 2022;9(4):430-436. doi:10.1515/dx-2022-0083. https:/…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865486/psn-pdf
    April 03, 2024 - Clinical informatics team members' perspectives on health information technology safety after experiential learning and safety process development: qualitative descriptive study. April 3, 2024 Recsky C, Rush KL, MacPhee M, et al. Clinical informatics team members' perspectives on health information technology saf…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853240/psn-pdf
    September 06, 2023 - Videos of simulated after action reviews: a training resource to support social and inclusive learning from patient safety events. September 6, 2023 McCarthy SE, Hogan C, Jenkins L, et al. Videos of simulated after action reviews: a training resource to support social and inclusive learning from patient safety eve…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47422/psn-pdf
    October 31, 2018 - The influence of stress responses on surgical performance and outcomes: literature review and the development of the surgical stress effects (SSE) framework. October 31, 2018 Chrouser KL, Xu J, Hallbeck S, et al. The influence of stress responses on surgical performance and outcomes: Literature review and the dev…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35908/psn-pdf
    March 03, 2011 - Patient safety in surgery. March 3, 2011 Makary MA, Sexton B, Freischlag JA, et al. Patient safety in surgery. Ann Surg. 2006;243(5):628-32; discussion 632-5. https://psnet.ahrq.gov/issue/patient-safety-surgery This AHRQ-supported study used a surgery-specific safety questionnaire (modified from the Safety Attitu…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836929/psn-pdf
    April 13, 2022 - The impact of "missed nursing care" or "care not done" on adults in health care: a rapid review for the Consensus Development Project. April 13, 2022 Willis E, Brady C. The impact of “missed nursing care” or “care not done” on adults in health care: A rapid review for the Consensus Development Project. Nurs Open. …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46631/psn-pdf
    March 20, 2018 - Simulation-based education to ensure provider competency within the healthcare system. March 20, 2018 Griswold S, Fralliccardi A, Boulet J, et al. Simulation-based Education to Ensure Provider Competency Within the Health Care System. Acad Emerg Med. 2018;25(2):168-176. doi:10.1111/acem.13322. https://psnet.ahrq.g…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45962/psn-pdf
    April 24, 2018 - Bridging leadership roles in quality and patient safety: experience of 6 US academic medical centers. April 24, 2018 Myers JS, Tess A, McKinney K, et al. Bridging Leadership Roles in Quality and Patient Safety: Experience of 6 US Academic Medical Centers. J Grad Med Educ. 2017;9(1):9-13. doi:10.4300/JGME-D-16-00065…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853619/psn-pdf
    September 20, 2023 - Defining speaking up in the healthcare system: a systematic review. September 20, 2023 Kane J, Munn L, Kane SF, et al. Defining speaking up in the healthcare system: a systematic review. J Gen Intern Med. 2023;38(15):3406-3413. doi:10.1007/s11606-023-08322-0. https://psnet.ahrq.gov/issue/defining-speaking-healthca…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45490/psn-pdf
    September 01, 2018 - Collaboration with regulators to support quality and accountability following medical errors: the communication and resolution program certification pilot. September 1, 2018 Gallagher TH, Farrell ML, Karson H, et al. Collaboration with Regulators to Support Quality and Accountability Following Medical Errors: The …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46538/psn-pdf
    February 21, 2018 - Adverse events in patients in home healthcare: a retrospective record review using trigger tool methodology. February 21, 2018 Schildmeijer KGI, Unbeck M, Ekstedt M, et al. Adverse events in patients in home healthcare: a retrospective record review using trigger tool methodology. BMJ Open. 2018;8(1):e019267. doi…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73085/psn-pdf
    January 01, 2022 - Multiple meanings of resilience: health professionals' experiences of a dual element training intervention designed to help them prepare for coping with error. March 31, 2021 Janes G, Harrison R, Johnson J, et al. Multiple meanings of resilience: health professionals' experiences of a dual element training interve…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72657/psn-pdf
    January 20, 2021 - Establishing a multi-institutional quality and patient safety consortium: collaboration across affiliates in a community-based medical school. January 20, 2021 Hillman E, Paul J, Neustadt M, et al. Establishing a multi-institutional quality and patient safety consortium: collaboration across affiliates in a commun…
  14. www.ahrq.gov/pqmp/implementation-qi/toolkit/h2h/introduction.html
    July 01, 2021 - Quality of Pediatric Hospital-to-Home Transitions Toolkit Introduction Previous Page Next Page Table of Contents Quality of Pediatric Hospital-to-Home Transitions Toolkit Introduction Overview About the Measure Key Driver Diagram Quality Improvement Strategies Improvement Data Other Re…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47618/psn-pdf
    January 30, 2019 - Making care better in the pediatric intensive care unit. January 30, 2019 Wolfe HA, Mack EH. Making care better in the pediatric intensive care unit. Transl Pediatr. 2018;7(4):267- 274. doi:10.21037/tp.2018.09.10. https://psnet.ahrq.gov/issue/making-care-better-pediatric-intensive-care-unit Pediatric critical care…
  16. www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit2.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 2. Factors Considered in Organization Selection Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Healthcare Cas…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863222/psn-pdf
    February 28, 2024 - Systematic review of morbidity and mortality meeting standardization: does it lead to improved professional development, system improvements, clinician engagement, and enhanced patient safety culture? February 28, 2024 Steel EJ, Janda M, Jamali S, et al. Systematic review of morbidity and mortality meeting standar…
  18. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/033-ss-action-chart-decolonization.docx
    April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI Action Chart for Implementing a Preoperative Decolonization Program Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries CUSP = Comprehensive Unit-based Safety Program; MRSA = methicillin-resistant Staphylococcus au…
  19. digital.ahrq.gov/care-setting/ambulance
    January 01, 2023 - Ambulance Digital EMS Point-of-Care Innovation to Improve Rural STEMI Outcomes Description This research will develop, implement, refine, and evaluate an app to support clinical decisions for ST-Elevation Myocardial Infarction care in rural areas by emergency medical services …
  20. www.ahrq.gov/hai/cusp/videos/index.html
    September 01, 2019 - CUSP Videos The following videos give examples of CUSP practices. Introduction About CUSP—A Doctor's Perspective About CUSP: A Nurse's Perspective About CUSP: Overview Assemble the Team The 4 E's Building Your CUSP Team Psychological Safety Physician Engagement Engage the Senior Executive …