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psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
February 28, 2024 - pages long) was that no one was going to read a document that lengthy to make a decision that needed to happen
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kline_32.pdf
March 03, 2008 - A Model of Care Delivery to Reduce Falls in a Major Cancer Center
A Model of Care Delivery to Reduce Falls
in a Major Cancer Center
Nancy E. Kline, PhD, RN, CPNP, FAAN; Bridgette Thom, MS; Wayne Quashie, MPH, RN;
Patricia Brosnan, MPH, RN; Mary Dowling, MSN, RN
Abstract
Falls are a leading cause of injuries…
-
psnet.ahrq.gov/node/841467/psn-pdf
December 14, 2022 - A framework for assessing reasoning about controversial
end-of-life clinical decisions.
December 14, 2022
Fedyk M, Fairman N, Romano PS, et al. A framework for assessing reasoning about controversial end-of-
life clinical decisions. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/framework-assessing-reasonin…
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psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - In Conversation with Lucy Savitz about Learning Health
Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. In Conversation with Lucy Savitz about Learning Health Systems for
Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learnin…
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psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
August 01, 2010 - I mean, how often when a patient is scheduled to be in a cath lab at 10:00 AM does it actually happen
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Tool_6_Pres_TX_508.pptx
July 23, 2010 - to prescribe is resolved to the satisfaction of everyone
Jack and Emily understand what is going to happen
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psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
September 01, 2005 - health care professionals, are going to be, and what will be the Agency's role in making these changes happen
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psnet.ahrq.gov/perspective/safety-and-medical-education
December 01, 2013 - some tension between the acts of research in improvement and the operational work to make improvement happen
-
www.ahrq.gov/sites/default/files/2024-09/halpern-report.pdf
January 01, 2024 - Final Progress Report: Measuring and Mitigating Patient Safety Threats Due to Strains on ICU Capacity
Measuring and Mitigating Patient Safety Threats Due to Strains on ICU Capacity
Principal Investigator: Scott D. Halpern, M.D., Ph.D.
Perelman School of Medicine, University of Pennsylvania
Other key team …
-
www.ahrq.gov/sites/default/files/2025-02/woods2-report.pdf
January 01, 2025 - Final Progress Report: Leveraging Existing Assessments of Risk Now (LEARN) Final Report
Leveraging Existing Assessments of Risk Now (LEARN)
Final Report
PI: Donna Woods, EdM, PhD
Jane Holl, MD, MPH; Sally Reynolds, MD; Robert Wears, MD; Ellen Schwalenstocker,
PhD; Jonathan Young; O…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/imp-handouts.pdf
June 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and ED Visits 1
On-Time
Preventable Hospital
and ED Visits:
Implementation
On-Time Preventable Hospital and ED Visits
Self-Assessment Scripted Exercise
Team consists of:
Facilitator [Tom]
Program Champion (Quality Assessment and…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_overview_impmodel.pptx
December 01, 2017 - Presentation: Program Overview
Program Overview
AHRQ Safety Program for Surgery
Onboarding
AHRQ Pub No. 16(18)-0004-15-EF
December 2017
Overview ‹#›
AHRQ Safety Program for Surgery – Onboarding
SAY:
You have embarked on a unique journey.
1
Never doubt that a small group of thoughtful, committed citizens ca…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/Part-I-SOPS-ASC-DatabaseReport.pdf
December 01, 2021 - 100% 100%
We are good at changing processes to make sure the same
patient safety problems don’t happen … Item C4) 84% 10.53% 38% 71% 79% 85% 91% 96% 100%
Staff are told about patient safety problems that happen
-
digital.ahrq.gov/sites/default/files/docs/quality-metrics-transcript-042811.pdf
December 31, 2007 - But it doesn’t take much
to think about many ways this can happen without any real change in the true … Of course in reality, you know there are reasons this doesn’t happen but it certain is a
theoretical … an approach will help fight the
perverse incentives that make it less desirable for providers who happen
-
psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view
November 01, 2018 - And stuff comes up in doctors' lives, they have to move and things happen. … Where does that tradeoff happen?
DM : This is an important point.
-
psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd
November 01, 2018 - And stuff comes up in doctors' lives, they have to move and things happen. … Where does that tradeoff happen?
DM : This is an important point.
-
psnet.ahrq.gov/node/33724/psn-pdf
February 01, 2012 - Mistakes may happen because you allow
people a little bit of room in their training to be autonomous
-
psnet.ahrq.gov/node/49783/psn-pdf
February 01, 2017 - How then did it happen, and
what are the implications for the use of checklists and order sets in medicine
-
psnet.ahrq.gov/node/33672/psn-pdf
September 01, 2008 - RW: Given that such a high percentage of errors in the medication process happen at a point that begins
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-slides-final508.pptx
June 02, 2025 - PowerPoint Presentation
Create a Safe
Medicine List Together
AHRQ
Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families
The Agency for Healthcare Research and Quality, or AHRQ, funded the development of a Guide to Improving Patient Safety in Primary Care Settings by Engagin…