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psnet.ahrq.gov/print/pdf/node/848754
January 01, 2025 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Implementation of Patient Safety Projects
Curated Library
Foundations
Leading change: why transformation efforts fail.
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
Kotter, a professor at Harvard Business School, outlines the eight stages …
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www.ahrq.gov/sites/default/files/2024-01/muller-report.pdf
January 01, 2024 - Final Progress Report: Medication Reconciliation: Bridging Communications Across the Continuum of Care
Title: Medication Reconciliation: Bridging Communications Across the Continuum of
Care
Principal Investigator and Team Members: Melinda Muller, MD, Lynn Belcher, RPh,
Melissa Blanchard, MP, Amy Caster-Winegeart, …
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hcup-us.ahrq.gov/reports/factsandfigures/figures/2006/2006_1_6a.jsp
January 01, 2006 - Exhibit 1.6 Discharge Status
Distribution of Inpatient Hospital Stays by Discharge Status, 2006
Percent Distribution
Routine
74%
Long-term Care and Other Facilities
12%
Home Health Care
9%
In-hospital Deaths
2%
Another Short-term Hospital
2%
Against Medi…
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psnet.ahrq.gov/node/40924/psn-pdf
February 23, 2015 - Interdisciplinary teamwork in hospitals: a review and
practical recommendations for improvement.
February 23, 2015
O'Leary KJ, Sehgal NL, Terrell G, et al. Interdisciplinary teamwork in hospitals: a review and practical
recommendations for improvement. J Hosp Med. 2012;7(1):48-54. doi:10.1002/jhm.970.
https://psne…
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psnet.ahrq.gov/node/35279/psn-pdf
June 30, 2009 - Results of a survey on medical error reporting systems in
Korean hospitals.
June 30, 2009
KIM J, Bates DW. Results of a survey on medical error reporting systems in Korean hospitals. Int J Med
Inform. 2005;75(2). doi:10.1016/j.ijmedinf.2005.06.005.
https://psnet.ahrq.gov/issue/results-survey-medical-error-reportin…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-213-section-6-tables-5-6.pdf
June 02, 2025 - CHIPRA 213: Section 6, Tables 5 and 6
Table 5: Agreement and Kappa Statistics for Sickle Cell Disease for Inter‐Rater Reliability at Three
Sites
Site Total Records N Agreed (%) Kappa Statistic
Hospital #1 2 100% 1.00
Hospital #2 4 100% 1.00
Hospital #3 10 100% 1.00
All Sites 16 100% 1.00
Table 6: …
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit5-16.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 5.16. Key Facilitators and Barriers to Organizing and Implementing Lean at Heights Hospital (From Conceptual Framework)
Previous Page Next Page
Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studie…
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs021301-miller-final-report-2015.pdf
January 01, 2015 - Health Information Technology in Ambulatory Care Settings: Effects on Quality and Disparities - Final Report
Health IT in Ambulatory Care Settings: Effects on Quality and Disparities
Final Progress Report
Principal Investigator: Amalia R. Miller,…
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hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/ca13.jsp
July 01, 2016 - Frequently Asked Questions about Collecting R/E/L Data
An official website of the Department of Health & Human Services
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FAQs
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/e1_pdi_monitorprogress.pdf
June 02, 2025 - Monitoring Progress for Sustainable Improvement
Pediatric Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
i Tool E.1
Monitoring Progress for Sustainable Improvement
What is the purpose of this tool? This tool provides guidance on how to monitor and report
your progres…
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psnet.ahrq.gov/node/49730/psn-pdf
April 01, 2015 - Transition to Nowhere
April 1, 2015
Farrell TW. Transition to Nowhere. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/transition-nowhere
The Case
A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension,
and chronic kidney disease was admitted to the hospital …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/e1_combo_monitorprogress.pdf
June 02, 2025 - Monitoring Progress for Sustainable Improvement
Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
Monitoring Progress for Sustainable Impro…
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psnet.ahrq.gov/issue/medicare-part-d-beneficiaries-serious-risk-opioid-misuse-or-overdose-closer-look
August 09, 2017 - Book/Report
Medicare Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose: A Closer Look.
Citation Text:
Medicare Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose: A Closer Look. HHS OIG Data Brief. Washington DC; Office of the Inspector General: May 4, 2020…
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psnet.ahrq.gov/issue/hardwiring-safety-computer-system-one-hospitals-actions-provide-technology-support-u-500
February 24, 2016 - Newspaper/Magazine Article
Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin.
Citation Text:
Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin. ISMP Medicatio…
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psnet.ahrq.gov/issue/hospital-experiences-responding-covid-19-pandemic-results-national-pulse-survey-march-23-27
December 23, 2020 - Book/Report
Classic
Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020.
Citation Text:
Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020. Was…
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psnet.ahrq.gov/issue/adverse-events-toolkit-clinical-guidance-identifying-harm
July 26, 2023 - Tools/Toolkit
Adverse Events Toolkit: Clinical Guidance for Identifying Harm
Citation Text:
Adverse Events Toolkit: Clinical Guidance for Identifying Harm Maxwell A. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2023. Report n…
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psnet.ahrq.gov/issue/how-reliable-your-hospital-qualitative-framework-analysing-reliability-levels
October 19, 2022 - Commentary
How reliable is your hospital? A qualitative framework for analysing reliability levels.
Citation Text:
Ikkersheim DE, Berg M. How reliable is your hospital? A qualitative framework for analysing reliability levels. BMJ Qual Saf. 2011;20(9):785-790.
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psnet.ahrq.gov/issue/overlooked-condition
October 03, 2018 - Newspaper/Magazine Article
An overlooked condition.
Citation Text:
Nicholas L. An overlooked condition. For diabetics, the hospital can be a dangerous place. Modern healthcare. 2005;35(46):24.
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Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML…
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psnet.ahrq.gov/issue/fda-guidance-document-hospital-bed-system-dimensional-and-assessment-guidance-reduce
July 01, 2009 - Organizational Policy/Guidelines
FDA Guidance Document: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment.
Citation Text:
FDA Guidance Document: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. Rockville MD: Center for Devices a…
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hcup-us.ahrq.gov/reports/factsandfigures/2007/TOC_2007.jsp
January 01, 2007 - HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2007
An official website of the Department of Health & Human Services
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