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441. Building a Safety Program Using Principles of Resilience Engineering | PSNet
     psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
     October 23, 2013 - resilience manifests in different work systems rather than on building a comprehensive readily usable toolkit … References Related Resources From the Same Author(s) An evidence-based toolkit … Perspective The Ongoing Journey to Prevent Patient Falls

442. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=2
     January 01, 2024 - Publication Date: July 2021 Generalizability and Spread of an Evidenced-based Fall Prevention Toolkit

443. The association between culture, climate and quality of care in primary health care teams. | PSNet
     psnet.ahrq.gov/issue/association-between-culture-climate-and-quality-care-primary-health-care-teams
     May 30, 2011 - July 31, 2019 A patient safety toolkit for family practices.

444. Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2007. | PSNet
     psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-safety-2007
     April 24, 2007 - March 22, 2006 Patients as Partners: Toolkit for Implementing National Patient Safety

445. Using smart pumps to understand and evaluate clinician practice patterns to ensure patient safety. | PSNet
     psnet.ahrq.gov/issue/using-smart-pumps-understand-and-evaluate-clinician-practice-patterns-ensure-patient-safety
     September 01, 2016 - November 4, 2020 Applying the Medications at Transitions and Clinical Handoffs Toolkit

446. The introduction of computerized physician order entry and change management in a tertiary pediatric hospital. | PSNet
     psnet.ahrq.gov/issue/introduction-computerized-physician-order-entry-and-change-management-tertiary-pediatric
     January 22, 2016 - April 12, 2023 Effects of a refined evidence-based toolkit and mentored implementation

447. Communication errors in radiology—pitfalls and how to avoid them. | PSNet
     psnet.ahrq.gov/issue/communication-errors-radiology-pitfalls-and-how-avoid-them
     September 24, 2017 - August 11, 2021 A patient safety toolkit for family practices.

448. Inability of providers to predict unplanned readmissions. | PSNet
     psnet.ahrq.gov/issue/inability-providers-predict-unplanned-readmissions
     December 05, 2007 - October 28, 2009 Effects of a refined evidence-based toolkit and mentored implementation

449. Moving beyond readmission penalties: creating an ideal process to improve transitional care. | PSNet
     psnet.ahrq.gov/issue/moving-beyond-readmission-penalties-creating-ideal-process-improve-transitional-care
     June 14, 2017 - April 5, 2013 Effects of a refined evidence-based toolkit and mentored implementation

450. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet
     psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
     February 26, 2025 - Jessica Behrhorst:  When we teach RCA 2 , we stress that it is a toolkit, not just one tool. … We have individuals going out into individual homes, where some serious events occur, like patient falls … Part of using this toolkit is related to understanding how we collaborate in our own organization to … to examine patterns across multiple events within a category (such as medication errors or patient falls … [Available at] Root cause analysis toolkit. MN Department of Health. June 20, 2024.

451. The Evolution of Root Cause Analysis | PSNet
     psnet.ahrq.gov/perspective/evolution-root-cause-analysis
     February 26, 2025 - Rather than being a rigid framework, the toolkit can be used in part or as a whole, making it highly … to examine patterns across multiple events within a category (such as medication errors or patient falls … [Available at] Root cause analysis toolkit. MN Department of Health. June 20, 2024. … Jessica Behrhorst:  When we teach RCA 2 , we stress that it is a toolkit, not just one tool. … We have individuals going out into individual homes, where some serious events occur, like patient falls

452. 'Corridor care' in the emergency department: managing patient care in non-clinical areas safely and efficiently. | PSNet
     psnet.ahrq.gov/issue/corridor-care-emergency-department-managing-patient-care-non-clinical-areas-safely-and
     May 19, 2021 - Related Resources From the Same Author(s) Effects of a refined evidence-based toolkit

453. Diagnostic errors in obstetric morbidity and mortality: methods for and challenges in seeking diagnostic excellence. | PSNet
     psnet.ahrq.gov/issue/diagnostic-errors-obstetric-morbidity-and-mortality-methods-and-challenges-seeking-diagnostic
     May 18, 2022 - November 13, 2024 CMQCC obstetric sepsis toolkit update: a patient-centered approach

454. Medication errors with pediatric liquid acetaminophen after standardization of concentration and packaging improvements. | PSNet
     psnet.ahrq.gov/issue/medication-errors-pediatric-liquid-acetaminophen-after-standardization-concentration-and
     May 19, 2021 - Related Resources From the Same Author(s) Effects of a refined evidence-based toolkit

455. Effect of critical access hospital conversion on patient safety. | PSNet
     psnet.ahrq.gov/issue/effect-critical-access-hospital-conversion-patient-safety
     October 19, 2022 - October 21, 2020 The Toolkit for Using the AHRQ Quality Indicators: How To Improve Hospital

456. Quality improvement through implementation of discharge order reconciliation. | PSNet
     psnet.ahrq.gov/issue/quality-improvement-through-implementation-discharge-order-reconciliation
     September 23, 2020 - December 18, 2013 A toolkit to disseminate best practices in inpatient medication reconciliation

457. What do hospital staff in the UK think are the causes of penicillin medication errors? | PSNet
     psnet.ahrq.gov/issue/what-do-hospital-staff-uk-think-are-causes-penicillin-medication-errors
     November 16, 2022 - August 25, 2021 A patient safety toolkit for family practices.

458. Inappropriate hospital admission as a risk factor for the subsequent development of adverse events: a cross-sectional study. | PSNet
     psnet.ahrq.gov/issue/inappropriate-hospital-admission-risk-factor-subsequent-development-adverse-events-cross
     March 09, 2022 - September 29, 2017 Antimicrobial Stewardship Toolkit.

459. Improving maternal safety at scale with the mentor model of collaborative improvement. | PSNet
     psnet.ahrq.gov/issue/improving-maternal-safety-scale-mentor-model-collaborative-improvement
     March 31, 2021 - August 21, 2024 CMQCC obstetric sepsis toolkit update: a patient-centered approach to

460. 2021: An AHRQ Year in Review | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/2021-ahrq-year-in-review.html
     January 01, 2022 - AHRQ Views: Blog posts from AHRQ leaders 2021: An AHRQ Year in Review JAN 11 2022 By David Meyers, M.D. David Meyers, M.D. Turning the calendar to a new year is a time for taking stock—reflecting on our accomplishments and setting our sights on where we want to go…