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9961. Final Progress Report: Impact of state policies on nursing home patient safety culture (pdf file)
      www.ahrq.gov/sites/default/files/2024-12/li-report.pdf
      January 01, 2024 - Improved organizational safety culture may, in turn, lead to better quality of care and resident outcomes

9962. Final Progress Report: Developing Peer-to-Peer Learning Tools for Critical Care Physicians (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/rosen-report.pdf
      January 01, 2024 - Final Progress Report: Developing Peer-to-Peer Learning Tools for Critical Care Physicians AHRQ Grant Final Progress Report Title of Project: Developing Peer-to-Peer Learning Tools for Critical Care Physicians: Peer- and Competency- based Ongoing Approach for Critical Healthcare Evaluations of Skills (P-COACHES) …

9963. Final progress report: Developing Evidence for Safety Surveillance from Device Adverse Event Reports (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/mao-report.pdf
      January 01, 2025 - Early failure of a small-diameter high-voltage implantable cardioverter-defibrillator lead.

9964. Final Progress Report: Developing Best Practices for Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/baker-report.pdf
      January 01, 2024 - Final Progress Report: Developing Best Practices for Patient Safety Developing Best Practices for Patient Safety Laurence Baker, PI Sara Singer, Co-PI Jeff Geppert, Co-Investigator Bruce Spurlock, Consultant David Classen, Consultant Stanford University Center for Health Policy August 2000 - August 2004 Federal P…

9965. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
      February 26, 2025 - : Awareness of potential for failure and emergence of new threats so that absence of error does not lead

9966. New Models of Primary Care Workforce - Case Example #6: Henry Ford Health System (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_6.pdf
      October 01, 2016 - a loose net of disconnected medical and social services” so women can “improve the conditions that lead

9967. Case Example #6: Henry Ford Health System | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-6.html
      July 01, 2019 - a loose net of disconnected medical and social services” so women can “improve the conditions that lead

9968. Fillmore (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/system/pfcasestudies/fillmore.pdf
      August 01, 2014 - , instructors must be effective teachers with a strong understanding of pedagogy and an ability to lead

9969. Final Progress Report: Distance Management of High-Risk Obstetrical Patients (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/ferguson2-report.pdf
      January 01, 2024 - Participants: The lead partner for the activities was Woman’s Hospital, a 225-bed, not-for-profit, women

9970. Final Progress Report: Medication Reconciliation: A Team Approach (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/greenwald-report.pdf
      January 01, 2024 - Final Progress Report: Medication Reconciliation: A Team Approach AHRQ Small Conference Grant Final Report Title of Project: Medication Reconciliation: A Team Appr oach Principal Investigator: Jeffrey L . Greenwald, MD, FHM Team Members: Jeffrey L. Greenwald, MD, FHM (SHM), PI and Conference Chair; …

9971. A Model-based Approach to Prioritizing Medical Safety Practices (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Marken.pdf
      January 01, 2004 - A Model-based Approach to Prioritizing Medical Safety Practices 409 A Model-based Approach to Prioritizing Medical Safety Practices Richard S. Marken Abstract This report shows how a model of skilled human performance can be used to evaluate safety practices aimed at reducing medical error when randomized tr…

9972. A Conceptual Framework for Studying the Safety of Transitions in Emergency Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Behara.pdf
      January 01, 2004 - A Conceptual Framework for Studying the Safety of Transitions in Emergency Care 309 A Conceptual Framework for Studying the Safety of Transitions in Emergency Care Ravi Behara, Robert L. Wears, Shawna J. Perry, Eric Eisenberg, Lexa Murphy, Mary Vanderhoef, Marc Shapiro, Christopher Beach, Pat Croskerry, Ka…

9973. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39110/psn-pdf
      June 10, 2018 - Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. November 5, 2009;14:1-3. https://psnet.ahrq.gov/issue/order-scanning-systems-may-pull-multiple-pages-through-scanner-same-time- leading-dru…

9974. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46081/psn-pdf
      April 19, 2017 - Why are medical errors still a leading cause of death? April 19, 2017 Headley M. https://psnet.ahrq.gov/issue/why-are-medical-errors-still-leading-cause-death This magazine article explores the need for robust research and effective reporting to better understand the prevalence of medical errors and how to prevent…

9975. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44239/psn-pdf
      September 29, 2017 - When medical care leads to harm—difficulty finding words: a teachable moment. September 29, 2017 Chamberlain E, DiVeronica M, Segura R. When medical care leads to harm- difficulty finding words: a teachable moment. JAMA Intern Med. 2015;175(8):1271-1272. doi:10.1001/jamainternmed.2015.2334. https://psnet.ahrq.gov/…

9976. Sources of NIS Data and State-Specific Restrictions 2005
      hcup-us.ahrq.gov/db/nation/nis/nis_2005_stspecific_restr.jsp
      January 01, 2005 - Sources of NIS Data and State-Specific Restrictions 2005 An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs…

9977. Sources of NIS Data and State-Specific Restrictions 2004
      hcup-us.ahrq.gov/db/nation/nis/nis_2004_stspecific_restr.jsp
      January 01, 2004 - Sources of NIS Data and State-Specific Restrictions 2004 An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs…

9978. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38598/psn-pdf
      June 03, 2010 - Leading successful rapid response teams: a multisite implementation evaluation. June 3, 2010 Donaldson N, Shapiro S, Scott M, et al. Leading successful rapid response teams: A multisite implementation evaluation. J Nurs Adm. 2009;39(4):176-81. doi:10.1097/NNA.0b013e31819c9ce9. https://psnet.ahrq.gov/issue/leading-…

9979. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43201/psn-pdf
      May 21, 2014 - New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings. May 21, 2014 Washington, DC: US Department of Health and Human Services; May 7, 2014. https://psnet.ahrq.gov/issue/new-hhs-data-shows-major-strides-made-patient-safety-leading-improved- care-and-savings Comparing safety…

9980. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45357/psn-pdf
      October 09, 2016 - Leading article: how can I optimise my role as a leader within the surgical team? October 9, 2016 Green B, Mitchell DA, Stevenson P, et al. Leading article: how can I optimise my role as a leader within the surgical team? Br J Oral Maxillofac Surg. 2016;54(8):847-850. doi:10.1016/j.bjoms.2016.05.035. https://psnet…