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digital.ahrq.gov/sites/default/files/docs/publication/r21hs020982-schoenthaler-final-report-2015.pdf
January 01, 2015 - Integrating health IT systems into
CBOs can increase their capacity to manage and coordinate the multiple
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effectivehealthcare.ahrq.gov/sites/default/files/s16.pdf
October 01, 2007 - ORIGINAL ARTICLE
Creating and Synthesizing Evidence With Decision Makers
in Mind
Integrating Evidence
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psnet.ahrq.gov/perspective/risk-management-and-patient-safety
December 01, 2010 - It's a matter of where you focus initially, and then integrating the clinical and legal implications.
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www.ahrq.gov/patient-safety/reports/hotline/appd.html
May 01, 2016 - Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events
Appendix D. Hotline Site Visit Interview Protocol
Previous Page
Table of Contents
Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/hotline/healthcare-safety-hotline-appendixd.pdf
February 01, 2014 - Appendix D. Hotline Site Visit Interview Protocol
Appendix D. Hotline Site Visit Interview Protocol
Interviewee(s):
Interviewee(s) title and location:
Number to call if person is late or does not show:
Interviewee(s)’ department (circle):
1. Implementation/operation of Health Care Safety …
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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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psnet.ahrq.gov/node/49824/psn-pdf
March 01, 2018 - Missing ECG and Missed Diagnosis Lead to Dangerous
Delay
March 1, 2018
O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
The Case
A 35-year-old woman with no prior cardiac history calle…
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psnet.ahrq.gov/node/49514/psn-pdf
July 01, 2006 - One ACE Too Many
July 1, 2006
Juurlink DN. One ACE Too Many. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/one-ace-too-many
The Case
A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure
presented to the emergency department (ED) with chest pain. An acut…
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psnet.ahrq.gov/node/866621/psn-pdf
August 28, 2024 - Application of Safety-II Principles
August 28, 2024
Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/application-safety-ii-principles
Traditional approaches to patient safety have often been reactive rather than proactive, seeki…
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digital.ahrq.gov/sites/default/files/docs/implementation/Porter.ppt
June 16, 2021 - Slide 1
Patient-centered HIT: a pediatric case study
Stephen C. Porter MD, MPH, MS
Assistant Professor, Harvard Medical School
Affiliate Faculty, Harvard-MIT Division of Health Sciences and Technology
Faculty, Division of Emergency Medicine,Children’s Hospital Boston
Email: stephen.porter@childrens.harva…
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psnet.ahrq.gov/node/33827/psn-pdf
February 01, 2017 - New Insights About Team Training From a Decade of
TeamSTEPPS
February 1, 2017
Baker DP, King HB, Battles J. New Insights About Team Training From a Decade of TeamSTEPPS. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
Perspective
Ten years ago, the Ag…
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psnet.ahrq.gov/node/73387/psn-pdf
March 17, 2021 - COVID-19 and the Built Environment
June 30, 2021
Joseph A, Scanlon MM, Fitall E, et al. COVID-19 and the Built Environment. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/covid-19-and-built-environment
Introduction
The “built environment” in healthcare refers to the hospital structure and any other fix…
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psnet.ahrq.gov/node/33868/psn-pdf
October 01, 2018 - Safety in the Retail Pharmacy
October 1, 2018
Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/safety-retail-pharmacy
Perspective
There are approximately 67,000 retail/community pharmacies dispensing 4.4 billion prescriptions each
year.(1) Many patients interact w…
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psnet.ahrq.gov/node/49598/psn-pdf
February 01, 2010 - Medication Reconciliation Pitfalls
February 1, 2010
Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
The Case
A 90-year-old woman who lived alone suffered a mechanical fall with subsequent hip fracture and was
brought to the eme…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.362_slideshow.ppt
December 01, 2015 - PowerPoint Presentation
Spotlight
Harm From Alarm Fatigue
This presentation is based on the December 2015
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Michele M. Pelter, RN, PhD, and Barbara J. Drew, RN, PhD, University of California, San …
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psnet.ahrq.gov/node/50393/psn-pdf
September 01, 2019 - Patient Safety and the Evolution of WebM&M and PSNet
September 1, 2019
Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet
Perspective
Progress in any field requires scholarship and dissem…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar5_pu_riskassesst-tools.pdf
January 01, 2012 - Using Pressure Ulcer Risk Assessment Tools in Care Planning
Using Pressure Ulcer
Risk Assessment Tools
in Care Planning
Presented by Elizabeth A. Ayello
Ph.D., RN, ACNS-BC, CWON, ETN, MAPWCA, FAAN
Excelsior College School of Nursing
Welcome!
Thank you for joining this webinar about how
to use pressure ulcer…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/rep2.html
June 01, 2010 - Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services
Evaluation of Measures in the Scan
Previous Page Next Page
Table of Contents
Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services
Executive Summary
Introduction and Scan Met…
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides3.html
October 01, 2017 - Module 3: Best Practices in Pressure Injury Prevention
Slide Presentation
Slide 1: Best Practices in Pressure Injury Prevention
ADD Hospital Name
Module 3
Slide 2: Best Practices
Best practices are those care processes—based on literature and expert opinion—that represent the best ways we curren…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/continuing-ed/moc_smsresources.pdf
July 01, 2014 - Supplemental Resources on Self-Management Support
External Resources On Self-Management Support
For Clinicians and Staff
Background, resources, and tools
• AHRQ’s Self‐Management Support Resource Library has basic information about self‐management
support plus links to a wide range of practical tools, technique…