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psnet.ahrq.gov/node/33935/psn-pdf
February 05, 2018 - The incidence and severity of adverse events affecting
patients after discharge from the hospital.
February 5, 2018
Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients
after discharge from the hospital. Ann Intern Med. 2003;138(3):161-7.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/39454/psn-pdf
October 04, 2017 - The Human Contribution: Unsafe Acts, Accidents and
Heroic Recoveries.
October 4, 2017
Reason J. Farnham Surrey, UK: Ashgate; 2008. ISBN: 9780754674023.
https://psnet.ahrq.gov/issue/human-contribution-unsafe-acts-accidents-and-heroic-recoveries
The British psychologist James Reason’s insights into the nature of hum…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/sicklecell-clinic-followup.pdf
June 02, 2025 - Sample Sickle Cell Clinic Follow-Up Care Process (2c.5)
Sample Sickle Cell Clinic Follow-Up Care Process (2c.5)
This diagram illustrates the process for reviewing the patient master list and identifying and contacting
individuals who require an annual TCD screen.
…
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psnet.ahrq.gov/node/34089/psn-pdf
December 23, 2008 - A national profile of patient safety in U.S. hospitals.
December 23, 2008
Romano PS, Geppert JJ, Davies SM, et al. A national profile of patient safety in U.S. hospitals. Health Aff
(Millwood). 2003;22(2):154-66.
https://psnet.ahrq.gov/issue/national-profile-patient-safety-us-hospitals
This AHRQ-supported study us…
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psnet.ahrq.gov/node/46741/psn-pdf
June 07, 2018 - Suffering in silence: medical error and its impact on
health care providers.
June 7, 2018
Robertson JJ, Long B. Suffering in Silence: Medical Error and its Impact on Health Care Providers. J
Emerg Med. 2018;54(4). doi:10.1016/j.jemermed.2017.12.001.
https://psnet.ahrq.gov/issue/suffering-silence-medical-error-and-…
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www.ahrq.gov/teamstepps-program/resources/videos/module-2.html
July 01, 2023 - Module 2 Training Simulation Video (Full)
YouTube embedded video: https://www.youtube-nocookie.com/embed/KTVYXsvAwQo
TeamSTEPPS Module 2 Full Team Leadership Training (13:10)
Review the facilitator guide (PDF, 559 KB) that explains how and when you'll need to access the other resources.
Additional Mat…
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psnet.ahrq.gov/node/40566/psn-pdf
June 29, 2011 - Comparison of computerized surveillance and manual
chart review for adverse events.
June 29, 2011
Tinoco A, Evans S, Staes CJ, et al. Comparison of computerized surveillance and manual chart review for
adverse events. J Am Med Inform Assoc. 2011;18(4):491-7. doi:10.1136/amiajnl-2011-000187.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/48022/psn-pdf
May 29, 2019 - Inappropriate opioid prescription after surgery.
May 29, 2019
Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. Lancet.
2019;393(10180):1547-1557. doi:10.1016/S0140-6736(19)30428-3.
https://psnet.ahrq.gov/issue/inappropriate-opioid-prescription-after-surgery
The overprescribing of o…
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psnet.ahrq.gov/node/837777/psn-pdf
August 03, 2020 - To err is human, unless you are a healthcare provider.
August 3, 2020
Zajicek J. Belmont Health Law J. 2020;4:79-135.
https://psnet.ahrq.gov/issue/err-human-unless-you-are-healthcare-provider
Intent to harm is a primary factor in the criminalization of patient injury. This article discusses the increase
of crimina…
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www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-eval-roadmap/ccre-roadmap-ap.html
July 01, 2013 - Clinical-Community Relationships Evaluation Roadmap
Appendices: Preliminary Work and Finding
Previous Page Next Page
Table of Contents
Clinical-Community Relationships Evaluation Roadmap
Executive Summary
1. Introduction and Purpose
2. Priority Questions and Recommendations
3. Conclusion
R…
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www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/tables-exhibits.html
August 01, 2022 - Designing Consumer Reporting Systems for Patient Safety Events
List of Tables and Exhibits
Previous Page Next Page
Table of Contents
Designing Consumer Reporting Systems for Patient Safety Events
Executive Summary
Chapter 1. Background
Chapter 2. Conceptual Framework and Design
Chapter 3. De…
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www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamilyex6.html
December 01, 2017 - Guide to Patient and Family Engagement
Exhibit 6. Strength of Evidence for Individual Characteristics of Target Audiences
Previous Page Next Page
Table of Contents
Guide to Patient and Family Engagement
Executive Summary
Introduction
Methods
Findings
Implications for the Guide
Summary an…
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www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamilyex7.html
July 01, 2018 - Guide to Patient and Family Engagement
Exhibit 7. Strength of Evidence for Organizational Culture
Previous Page Next Page
Table of Contents
Guide to Patient and Family Engagement
Executive Summary
Introduction
Methods
Findings
Implications for the Guide
Summary and Discussion
Next Step…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/tips.html
March 01, 2017 - Tips for Implementing Interventions
These tips are to help educators prepare for a live training session and facilitate an interactive experience.
Reinforce that the session focuses on ways the team can work together to improve resident safety and reduce catheter-associated urinary tract infections (CAUTIs)…
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www.ahrq.gov/patient-safety/reports/hotline/eval4.html
May 01, 2016 - learned about the project, vetted the idea of participation with the vice president of safety, and then discussed … The group discussed successful examples of each type of effort.
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www.ahrq.gov/sites/default/files/publications/files/pfcases.pdf
August 01, 2014 - The team discussed curriculum development, course and session learning objectives,
student performance
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module2/mod2-facguide.html
March 01, 2017 - Module 2: Senior Leader Engagement: Facilitator Notes
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Slide 1: Module 2: Senior Leader Engagement
Say:
The Senior Leader Engagement module focuses on the role and responsibilities of the senior leader within the facility safety team. Engaging a senior l…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/prostate-cancer-surveillance_executive.pdf
December 01, 2011 - survey of Australian
men who had a urological consultation reported that 71
percent of the urologists discussed … observational
management strategies, compared with 92 percent who
discussed RP and 87 percent RT. … The same study reported
that 20 percent of patients thought that treatment options
were not discussed … rural residents in North Carolina as to whether the
option of observational management strategies was
discussed
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psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
May 01, 2016 - We have previously discussed electrode placement and preparation, default alarm limits and delays, and … , led to a 43% reduction in critical alarms.( 15 )
Patient Education
All previous interventions discussed
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/psychiatric-readmissions_research-protocol.pdf
December 31, 2014 - psychiatric-readmissions-protocols-140904
Evidence-based Practice Center
Technical Brief Protocol
Project Title: Management Strategies to Reduce Psychiatric Readmi…