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www.ahrq.gov/sites/default/files/2025-02/mao-report.pdf
January 01, 2025 - Final progress report: Developing Evidence for Safety Surveillance from Device Adverse Event Reports
Final progress report
Developing Evidence for Safety Surveillance from Device Adverse Event Reports
Grant number: 1R03HS026291-01
Supported by AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
Research Team
Principal invest…
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www.ahrq.gov/workingforquality/events/webinar-introducing-nine-levers-to-support-the-aims-and-priorities.html
November 01, 2016 - Webinar Transcript - National Quality Strategy Webinar: Introducing Nine Levers to Support the Aims and Priorities
May 13, 2014
Download accessible version of slides (PDF, 1.1 MB)
Introducing Nine Levers to Support the Aims and Priorities [Slide 1]
Ann Gordon: Welcome to today's event featuring t…
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pso.ahrq.gov/faq
April 01, 2023 - SHARE:
Frequently Asked Questions
Frequently asked questions and definition of terms used in the Patient Safety Act or Patient Safety Rule are summarized here solely for convenience; always rely on the actual text of the Patient Safety Act or Patient Safety …
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psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety
Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
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Citation Text:
Vogus T, Lee M, Mos…
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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety
Robert M. Wachter, MD | October 1, 2009
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Wachter R. The Media: An Essential, If Sometimes Arbitrary, Pro…
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psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety
Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
Also Read the Essay
View more articles from the same authors.
Ci…
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psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
May 01, 2014 - In Conversation With… Didier Pittet, MD, MS
May 1, 2014
Also Read an Essay
Citation Text:
In Conversation With… Didier Pittet, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Sirio.pdf
June 15, 2003 - Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative
153
Shared Learning and the Drive to Improve
Patient Safety: Lessons Learned from the
Pittsburgh Regional Healthcare Initiative
Carl A. Sirio, Donna J. Keyser, Heidi Norman,
Robert J. We…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
February 26, 2008 - Error Producing Conditions in the Intensive Care Unit
Error Producing Conditions in the
Intensive Care Unit
Frank A. Drews, PhD; Adrian Musters, BS; Matthew H. Samore, MD
Abstract
Up to 98,000 patients die because of human error in U.S. hospitals each year. Among the areas
where errors occur frequently is t…
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integrationacademy.ahrq.gov/news-and-events/calendar/event/23308
June 10, 2025 - An official website of the Department of Health & Human Services
Search All AHRQ Sites
Careers
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The Academy
Integrating Behavioral Health & Primary Care
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psnet.ahrq.gov/issue/what-can-physicians-do-help-curb-opioid-crisis
December 18, 2019 - Newspaper/Magazine Article
What can physicians do to help curb the opioid crisis?
Citation Text:
What can physicians do to help curb the opioid crisis? Bendix J.
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psnet.ahrq.gov/issue/ajr-podcast-series-diagnostic-excellence-and-error
November 19, 2014 - Audiovisual
AJR Podcast Series on Diagnostic Excellence and Error.
Citation Text:
AJR Podcast Series on Diagnostic Excellence and Error. Deng F, ed. AJR Am J Roentgenol. July 2024-February 2025.
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psnet.ahrq.gov/issue/case-shook-medicine
October 24, 2012 - Newspaper/Magazine Article
A case that shook medicine.
Citation Text:
A case that shook medicine. Lerner BH.
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psnet.ahrq.gov/issue/engaging-patients-improving-ambulatory-care
January 17, 2024 - Book/Report
Engaging Patients in Improving Ambulatory Care.
Citation Text:
Engaging Patients in Improving Ambulatory Care. Aligning Forces for Quality. Princeton, NJ: Robert Wood Johnson Foundation; 2013.
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effectivehealthcare.ahrq.gov/sites/default/files/web-based_willis_respondent.pdf
January 01, 2009 - Willis_respondent_DuBenske_4
Source:
Eisenberg
Center
Conference
Series
2009,
Translating
Information
Into
Action:
Improving
Quality
of
Care
Through
Interactive
Media,
Effective
Health
Care
Program
Web
site
(http://www.effectivehealthcar…
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psnet.ahrq.gov/issue/ismp-survey-iv-push-medication-practices
January 26, 2023 - Press Release/Announcement
ISMP Survey on IV Push Medication Practices.
Citation Text:
ISMP Survey on IV Push Medication Practices. Institute for Safe Medication Practices; ISMP.
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/event-tree-analysis
January 01, 2023 - Event Tree Analysis
Acronym
ETA
Description
An event tree analysis (ETA) examines the different paths that can be taken in a given scenario. Each step consists of a node and corresponding exit lines for each possible outcome at that step. The tool was originally developed for use in system rel…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/kepner-tregoe-matrix
January 01, 2023 - Kepner-Tregoe Matrix
Also Known As
Is-Is Not Matrix
Kepner and Tregoe Method
Description
A Kepner-Tregoe matrix is used to find causes of a problem. It isolates the who, what, when, where, and how aspects of an event, keeping the focus on the elements that have an impact on the event and…
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psnet.ahrq.gov/issue/stop-using-these-adult-bed-rails-warns-consumer-product-safety-commission
June 21, 2023 - Newspaper/Magazine Article
Stop using these adult bed rails, warns the Consumer Product Safety Commission.
Citation Text:
Stop using these adult bed rails, warns the Consumer Product Safety Commission. Treisman R. National Public Radio. June 6, 2022
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psnet.ahrq.gov/issue/medical-errors-still-claiming-many-lives
September 19, 2007 - Newspaper/Magazine Article
Medical errors still claiming many lives.
Citation Text:
Medical errors still claiming many lives. Weise E. USA Today. May 18, 2005.
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