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psnet.ahrq.gov/issue/no-more-blame-shame-developing-event-reporting-systems-may-go-long-way-reducing-patient-care
December 21, 2017 - Newspaper/Magazine Article
No more blame & shame: developing event-reporting systems may go a long way to reducing patient care errors in EMS.
Citation Text:
Rajasekaran K, Fairbanks RJ, Shah M. No more blame & shame. Developing event-reporting systems may go a long way to reducing patie…
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psnet.ahrq.gov/issue/when-things-go-wrong-how-health-care-organizations-deal-major-failures
March 13, 2013 - Commentary
Classic
When things go wrong: how health care organizations deal with major failures.
Citation Text:
Walshe K, Shortell SM. When things go wrong: how health care organizations deal with major failures. Health Aff (Millwood). 2004;23(3):103-11.
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psnet.ahrq.gov/perspective/safety-dentistry
August 01, 2016 - Safety In Dentistry
Rachel Badovinac Ramoni, DMD, ScD; Muhammad Walji, PhD; and Elsbeth Kalenderian, DDS, MPH, PhD | August 1, 2016
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Ramoni R, Walji MF, Kalenderian E. Safety In De…
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - SPOTLIGHT CASE
What Happened on Telemetry?
Citation Text:
Sandau KE, Funk M. What Happened on Telemetry?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Davis.pdf
February 12, 2004 - Anyone who was
familiar with the data or anyone who was going to utilize the database was
included
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www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool6.html
March 01, 2025 - Summary Developing a monitoring plan as suggested in this tool will help you identify what is going well
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www.ahrq.gov/research/findings/final-reports/iomracereport/reldata1.html
April 01, 2018 - Going beyond the OMB categories to develop response options that are more relevant for the identification
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/about/proposed-changes-cahps-c&g-survey2015.pdf
March 01, 2015 - How long have you been going to this provider?
R: <6m; 6m-<1yr; 1yr-<3yr; 3yr-<5yr; 5+yr
Q4.
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www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/redtool6.html
March 01, 2025 - Summary Developing a monitoring plan as suggested in this tool will help you identify what is going well
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/tool_safe-oxytocin.docx
May 01, 2017 - knowing what the patient’s plan is through briefings and team management,
· being aware of what is going
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www.ahrq.gov/policymakers/chipra/overview/background/next-steps.html
December 01, 2009 - Frequency of on-going prenatal care.
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www.ahrq.gov/sites/default/files/2025-02/nishisaki2-report.pdf
January 01, 2025 - demonstrating competence in tracheal intubation skills may be needed for pediatric residents
who are going
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www.ahrq.gov/sites/default/files/2024-07/picone-jollis-report.pdf
January 01, 2024 - patients (the median hospital volume using all admissions is
over 200 admissions per year; if we were going
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/lessons/lessons-using-pqms.pdf
January 01, 2016 - . … if you’re going to
hold someone accountable for
follow up after mental health stay
but you’re
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/guide-appcusp.pdf
December 01, 2017 - Our surgical site infection (SSI) rate is not
going to budge if all we do is exchange blame.
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/advance-organizational-safety-strategies-slides.pdf
June 18, 2024 - Milestones of the Journey
• Walk – don’t run
• Anticipate the bumps – change management
• If we are going
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www.ahrq.gov/hai/cauti-tools/facil-guide/preventing-cauti-icu-setting-transcript.html
February 01, 2023 - Going a step further, if such a patient develops a CAUTI, then using an antibiotic to treat the infection
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_ssibundle_facnotes.docx
December 01, 2017 - They should represent local wisdom and local defects—what’s going on in one hospital will differ from
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www.ahrq.gov/hai/tools/surgery/modules/implementation/ssi-bundle-fac-notes.html
October 01, 2020 - They should represent local wisdom and local defects—what’s going on in one hospital will differ from
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/learn_from_defects.docx
December 01, 2017 - How were we going to address the fact that surgeons like the OR cool when they’re operating?