-
psnet.ahrq.gov/node/34763/psn-pdf
March 07, 2005 - The Limits of Safety: Organizations, Accidents and
Nuclear Weapons.
March 7, 2005
Sagan SD. Princeton NJ: Princeton University Press; 1993. ISBN: 9780691032214.
https://psnet.ahrq.gov/issue/limits-safety-organizations-accidents-and-nuclear-weapons
Two competing paradigms dominate the study of the hazards associate…
-
psnet.ahrq.gov/node/47930/psn-pdf
May 01, 2019 - Evolving quality improvement support strategies to
improve Plan–Do–Study–Act cycle fidelity: a retrospective
mixed-methods study.
May 1, 2019
McNicholas C, Lennox L, Woodcock T, et al. Evolving quality improvement support strategies to improve
Plan-Do-Study-Act cycle fidelity: a retrospective mixed-methods study. …
-
psnet.ahrq.gov/node/73364/psn-pdf
January 01, 2022 - Impact of opioid administration in the intensive care unit
and subsequent use in opioid-naïve patients.
June 9, 2021
Krancevich NM, Belfer JJ, Draper HM, et al. Impact of opioid administration in the intensive care unit and
subsequent use in opioid-naïve patients. Ann Pharmacother. 2022;56(1):52-59.
doi:10.1177/10…
-
psnet.ahrq.gov/node/41647/psn-pdf
July 02, 2014 - Seen through their eyes: residents' reflections on the
cognitive and contextual components of diagnostic errors
in medicine.
July 2, 2014
Ogdie AR, Reilly JB, Pang WG, et al. Seen through their eyes: residents' reflections on the cognitive and
contextual components of diagnostic errors in medicine. Acad Med. 2012;…
-
psnet.ahrq.gov/node/43072/psn-pdf
November 21, 2016 - Physician attitudes toward family-activated medical
emergency teams for hospitalized children.
November 21, 2016
Paciotti B, Roberts KE, Tibbetts KM, et al. Physician attitudes toward family-activated medical emergency
teams for hospitalized children. Jt Comm J Qual Patient Saf. 2014;40(4):187-192.
https://psnet.a…
-
psnet.ahrq.gov/node/39543/psn-pdf
May 19, 2010 - Hospital Survey on Patient Safety Culture: 2010 User
Comparative Database Report.
May 19, 2010
Sorra J, Famolaro T, Dyer N, Nelson D, Khanna K. Rockville, MD: Agency for Healthcare Research and
Quality; March 2010. AHRQ Publication No. 10-0026.
https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-20…
-
psnet.ahrq.gov/node/38673/psn-pdf
April 30, 2014 - New world of patient safety. 23rd Annual Samuel Jason
Mixter Lecture.
April 30, 2014
Leape L. New world of patient safety: 23rd Annual Samuel Jason Mixter lecture. Arch Surg.
2009;144(5):394-8. doi:10.1001/archsurg.2009.78.
https://psnet.ahrq.gov/issue/new-world-patient-safety-23rd-annual-samuel-jason-mixter-lectu…
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/02-sops-overview-webcast-bakdash.pdf
June 02, 2025 - AHRQ’s Surveys on Patient Safety Culture® for New Users - Jonathan Bakdash
AHRQ’s Surveys on Patient Safety Culture®
(SOPS®) Program
Jonathan Bakdash, Ph.D.
Center for Quality Improvement and Patient Safety, AHRQ
Agency for Healthcare Research and Quality
• AHRQ is:
► A research and science-based agency of
t…
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T3-Antibiogram_Factsheet_Phase_3.doc
January 01, 2014 - Comprehensive Antibiogram Toolkit: Phase 1
Antibiogram Factsheet
What is an antibiogram?
Antibiograms aggregate information about susceptibility patterns of organisms to commonly prescribed antibiotics. Antibiograms display the organisms present in clinical specimens sent by the prescribing clinician (physician, nurs…
-
psnet.ahrq.gov/node/37792/psn-pdf
February 15, 2011 - Exploring organizational context and structure as
predictors of medication errors and patient falls.
February 15, 2011
Mark BA, Hughes LC, Belyea M, et al. Exploring Organizational Context and Structure as Predictors of
Medication Errors and Patient Falls. J Patient Saf. 2008;4(2). doi:10.1097/pts.0b013e3181695671.…
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/3_TK1_T4-Implementation_Planning_Sample_Agenda_final.docx
October 01, 2016 - Tool 4. Implementation Planning Sample Agenda
Agenda for Antimicrobial Stewardship Planning
Date:
Time:
Participant’s Name
Discipline
Initials a
a Initials or signatures are only necessary if requested by State Survey Agency staff.
Nursing Home
Ant…
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/3_TK1_T4-Implementation_Planning_Sample_Agenda_final.pdf
October 01, 2016 - Nursing Home
Antimicrobial Stewardship Guide
Implement, Monitor, & Sustain a Program
Toolkit 1. Start an Antimicrobial Stewardship Program
Tool 4. Implementation Planning Sample Agenda
Agenda for Antimicrobial Stewardship Planning
Date: __________________________________
Time: _________________________…
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P1T4-Antibiogram_Factsheet_Phase_1.doc
January 01, 2014 - Comprehensive Antibiogram Toolkit: Phase 1
Antibiogram Factsheet
What is an antibiogram?
Antibiograms aggregate information about susceptibility patterns of organisms to commonly prescribed antibiotics. Antibiograms display the organisms present in clinical specimens sent by the prescribing clinician (physician, nurs…
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/sopsvaluewebcast-intro.pdf
January 09, 2018 - Value and Efficiency Supplemental Items for Hospitals and Medical Offices - INTRO
New AHRQ SOPS™ Value and
Efficiency Supplemental Items for
Hospitals and Medical Offices
Webcast
January 9, 2018
2:00-3:00 ET
Our Focus Today
• Describe the development of the new SOPSTM
Value and Efficiency Supplemental Items …
-
www.ahrq.gov/ncepcr/research/behavioral-health/index.html
February 01, 2024 - Behavioral Health and Substance Use Disorders
Behavioral health problems, which include mental health and substance use disorders, are among the most common conditions seen in primary care settings. Behavioral health conditions often affect medical illnesses. Integrated behavioral healthcare blends primary care…
-
www.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
March 01, 2021 - AHRQ Quality and Safety Review System (QSRS)
Mission
AHRQ has developed and tested an improved patient safety surveillance system to replace the Medicare Patient Safety Monitoring System (MPSMS). The new system is known as the Quality and Safety Review System (QSRS). The QSRS relies on clinical information re…
-
www.uspreventiveservicestaskforce.org/home/getfilebytoken/URK4KUpCK3gafGrdaLzYDJ
Low-Dose Aspirin for the Prevention of Morbidity and Mortality From Preeclampsia: Clinical Summary of USPSTF Recommendation
LOW-DOSE ASPIRIN USE FOR THE PREVENTION OF MORBIDITY AND MORTALITY FROM PREECLAMPSIA
CLINICAL SUMMARY OF U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATION
Population Asymptomatic pregna…
-
www.ahrq.gov/cpi/about/nac/snac-zimmerman.html
December 01, 2021 - SNAC Member: Jaime Zimmerman, M.P.H., PMP
Senior Program Advisor
Designated Management Official, National Advisory Council
Office of the Director
Agency for Healthcare Research and Quality
Jaime Zimmerman, M.P.H., PMP, serves as a senior program advisor in the Office of the Director at the Agency for Heal…
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/111-cusp-learning-from-defects-worksheet.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Investigating a Defect Worksheet
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion SurgeriesOwner: ____________________________
Date Defect Occurred: ________________
Date Investigation Initiated: ___________
Use the Learning From …
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/111-ss-cusp-lfd-worksheet-a3.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Investigating a Defect Worksheet
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion SurgeriesOwner: ____________________________
Date Defect Occurred: ________________
Date Investigation Initiated: ___________
Use the Learning From …