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psnet.ahrq.gov/node/73220/psn-pdf
May 05, 2021 - Identifying barriers to and opportunities for telehealth
implementation amidst the COVID-19 pandemic by using
a human factors approach: a leap into the future of health
care delivery?
May 5, 2021
Zhang T, Mosier J, Subbian V. Identifying barriers to and opportunities for telehealth implementation amidst
the COVID…
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psnet.ahrq.gov/issue/affordable-health-care-floridians-act
January 15, 2025 - Legislation/Regulation
Affordable Health Care for Floridians Act.
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August 27, 2008
Established the patient safety center in the st…
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www.ahrq.gov/takeheart/beyond/million-hearts/index.html
November 01, 2022 - Million Hearts®
Million Hearts ® , a national initiative co-led by the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS) with the goal of preventing 1 million acute cardiovascular events by 2027, is working with cardiac rehabilitation (CR) professionals, pub…
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psnet.ahrq.gov/node/47376/psn-pdf
November 02, 2018 - Assessing information sources to elucidate diagnostic
process errors in radiologic imaging—a human factors
framework.
November 2, 2018
Cochon L, Lacson R, Wang A, et al. Assessing information sources to elucidate diagnostic process errors
in radiologic imaging - a human factors framework. J Am Med Info Asso. 2018;…
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psnet.ahrq.gov/node/47385/psn-pdf
April 27, 2019 - Reasons for repeat rapid response team calls, and
associations with in-hospital mortality.
April 27, 2019
Chalwin R, Giles L, Salter A, et al. Reasons for Repeat Rapid Response Team Calls, and Associations with
In-Hospital Mortality. Jt Comm J Qual Patient Saf. 2019;45(4):268-275. doi:10.1016/j.jcjq.2018.10.005.
h…
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psnet.ahrq.gov/node/865920/psn-pdf
May 22, 2024 - Role of knowledge and reasoning processes as
predictors of resident physicians' susceptibility to
anchoring bias in diagnostic reasoning: a randomised
controlled experiment.
May 22, 2024
Mamede S, Zandbergen A, de Carvalho-Filho MA, et al. Role of knowledge and reasoning processes as
predictors of resident physic…
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psnet.ahrq.gov/node/46372/psn-pdf
September 13, 2017 - Impact of a successful speaking up program on health-
care worker hand hygiene behavior.
September 13, 2017
Linam MW; Honeycutt MD; Gilliam CH; Wisdom CM; Deshpande JK.
https://psnet.ahrq.gov/issue/impact-successful-speaking-program-health-care-worker-hand-hygiene-
behavior
Improving hand hygiene in health care f…
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psnet.ahrq.gov/node/44616/psn-pdf
November 04, 2015 - Development of "SWARM" as a model for high reliability,
rapid problem solving, and institutional learning.
November 4, 2015
Williams EA, Nikolai DA, Ladwig L, et al. Development of "SWARM" as a Model for High Reliability, Rapid
Problem Solving, and Institutional Learning. Jt Comm J Qual Patient Saf. 2015;41(11):508…
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psnet.ahrq.gov/node/838132/psn-pdf
September 21, 2022 - Pathology trainees rarely report safety incidents: a review
of 13,722 safety reports and a call to action.
September 21, 2022
Harris CK, Chen Y, Yarsky B, et al. Pathology trainees rarely report safety incidents: a review of 13,722
safety reports and a call to action. Acad Pathol. 2022;9(1):100049. doi:10.1016/j.ac…
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psnet.ahrq.gov/node/866818/psn-pdf
September 25, 2024 - Academic half day improves resident perception of
education without compromising patient safety.
September 25, 2024
Spence MC, Sugarman A, Uong A, et al. Academic half day improves resident perception of education
without compromising patient safety. Acad Pediatr. 2024;24(6):1010-1016. doi:10.1016/j.acap.2024.02.00…
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psnet.ahrq.gov/node/46849/psn-pdf
May 23, 2018 - 1,300 days and counting: a risk model approach to
preventing retained foreign objects (RFOs).
May 23, 2018
Duggan EG, Fernandez J, Saulan MM, et al. 1,300 Days and Counting: A Risk Model Approach to
Preventing Retained Foreign Objects (RFOs). Jt Comm J Qual Patient Saf. 2018;44(5):260-269.
doi:10.1016/j.jcjq.2017.…
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psnet.ahrq.gov/node/60958/psn-pdf
September 30, 2020 - Characteristics and unexpected COVID-19 diagnoses in
resuscitation room patients during the COVID-19 outbreak
- a retrospective case series.
September 30, 2020
Bergrath S, Aretz O, Haake H, et al. Characteristics and unexpected COVID-19 diagnoses in resuscitation
room patients during the COVID-19 outbreak - a retr…
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www.ahrq.gov/evidencenow/projects/state/how-to-guide/guide6.html
August 01, 2024 - Developing and Sustaining State-Based Infrastructure To Support Primary Care Quality Improvement
Conclusion
Previous Page Next Page
Table of Contents
Developing and Sustaining State-Based Infrastructure To Support Primary Care Quality Improvement
Using This Guide
1. Background and Introduction
…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-pda.pdf
June 02, 2025 - NICU Family Information Packet, Appendix B, Patent Ductus Arteriosus
Patent Ductus Arteriosus
Characteristics
■ A persistent open connection beyond 3 months of age between the pulmonary artery and the
aorta with blood flow from the aorta to the pulmonary artery.
■ An open ductus may lead to:
– Congestive heart…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-weaning.pdf
June 02, 2025 - NICU Family Information Packet, Appendix B, Weaning
Weaning
Description
■ The introduction of solid food feedings and the gradual replacement of milk by solid food as
the main source of energy and nutrients.
■ Shared pleasure in eating and feeding enhances the relationship between infants and their
caregivers.
…
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psnet.ahrq.gov/node/47690/psn-pdf
March 13, 2019 - I-PASS mentored implementation handoff curriculum:
champion training materials.
March 13, 2019
O'Toole JK, Starmer AJ, Calaman S, et al. I-PASS Mentored Implementation Handoff Curriculum:
Champion Training Materials. MedEdPORTAL. 2019;15:10794. doi:10.15766/mep_2374-8265.10794.
https://psnet.ahrq.gov/issue/i-pass-…
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psnet.ahrq.gov/node/47479/psn-pdf
December 12, 2018 - "Closing the loop": a mixed-methods study about
resident learning from outcome feedback after patient
handoffs.
December 12, 2018
Shenvi EC, Feupe SF, Yang H, et al. "Closing the loop": a mixed-methods study about resident learning
from outcome feedback after patient handoffs. Diagnosis (Berl). 2018;5(4):235-242. …
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psnet.ahrq.gov/node/44104/psn-pdf
July 16, 2015 - Errors upstream and downstream to the Universal
Protocol associated with wrong surgery events in the
Veterans Health Administration.
July 16, 2015
Paull DE, Mazzia L, Neily J, et al. Errors upstream and downstream to the Universal Protocol associated
with wrong surgery events in the Veterans Health Administration.…
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psnet.ahrq.gov/node/37903/psn-pdf
May 09, 2013 - Safe Surgery.
May 9, 2013
World Health Organization.
https://psnet.ahrq.gov/issue/safe-surgery-saves-lives-second-global-patient-safety-challenge
This initiative provides a surgical safety checklist and related educational and training materials building on
the Second Global Patient Safety Challenge vision to enco…
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psnet.ahrq.gov/node/36675/psn-pdf
January 18, 2011 - Target-focused medical emergency team training using a
human patient simulator: effects on behaviour and
attitude.
January 18, 2011
Wallin C-J, Meurling L, Hedman L, et al. Target-focused medical emergency team training using a human
patient simulator: effects on behaviour and attitude. Med Educ. 2007;41(2):173-80…