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www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/learning-modules/nh-learning-module-guide.pdf
November 01, 2021 - Nursing Home Learning Module Guide
Nursing Home Learning Module Guide
• The Agency for Healthcare Research and Quality developed short learning modules for nursing home staff
who provide direct care to or interact with residents and their families. These brief modules address issues
many nursing homes are facing …
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www.ahrq.gov/chsp/events/coe-workshop1.html
December 01, 2022 - First Annual Centers of Excellence Workshop
Overview
The first annual meeting of the Centers of Excellence under the Comparative Health System Performance (CHSP) Initiative was held in September 2016 and was attended by AHRQ, the Centers of Excellence, and the Coordinating Center. The purpose of these meeting…
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psnet.ahrq.gov/issue/bone-break-hot-debrief-tool-reduce-second-victim-syndrome-nurses
August 02, 2015 - Study
BONE break: a hot debrief tool to reduce second victim syndrome for nurses.
Citation Text:
Hess A, Flicek T, Watral AT, et al. BONE break: a hot debrief tool to reduce second victim syndrome for nurses. Jt Comm J Qual Patient Saf. 2024;50(9):673-677. doi:10.1016/j.jcjq.2024.05.005.…
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psnet.ahrq.gov/issue/association-between-parent-comfort-english-and-adverse-events-among-hospitalized-children
June 29, 2022 - Study
Association between parent comfort with English and adverse events among hospitalized children.
Citation Text:
Khan A, Yin HS, Brach C, et al. Association between parent comfort with English and adverse events among hospitalized children. JAMA Pediatr. 2020;174(12):e203215. doi:10.…
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psnet.ahrq.gov/issue/implementing-strategies-identify-and-mitigate-adverse-safety-events-case-study-unplanned
May 24, 2012 - Study
Implementing strategies to identify and mitigate adverse safety events: a case study with unplanned extubations.
Citation Text:
Hatch D, Rivard M, Bolton J, et al. Implementing Strategies to Identify and Mitigate Adverse Safety Events: A Case Study with Unplanned Extubations. Jt Co…
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psnet.ahrq.gov/issue/quality-improvement-initiative-using-peer-audit-and-feedback-improve-compliance-surgical
March 24, 2021 - Study
A quality improvement initiative using peer audit and feedback to improve compliance with the surgical safety checklist.
Citation Text:
Fridrich A, Imhof A, Staender S, et al. A quality improvement initiative using peer audit and feedback to improve compliance. Int J Qual Health C…
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psnet.ahrq.gov/issue/decreasing-misdiagnoses-urinary-tract-infections-pediatric-emergency-department
October 26, 2022 - Study
Decreasing misdiagnoses of urinary tract infections in a pediatric emergency department.
Citation Text:
Ostrow O, Prodanuk M, Foong Y, et al. Decreasing misdiagnoses of urinary tract infections in a pediatric emergency department. Pediatrics. 2022;150(1):e2021055866. doi:10.1542/pe…
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psnet.ahrq.gov/issue/differential-perceptions-what-constitutes-medical-error-associated-electronic-medical-records
August 09, 2023 - Commentary
Differential perceptions of what constitutes a medical error associated with electronic medical records.
Citation Text:
Koppel R, Kuziemsky C, Elkin PL, et al. Differential perceptions of what constitutes a medical error associated with electronic medical records. Stud Health …
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psnet.ahrq.gov/issue/creating-high-reliability-health-care-organizations
September 20, 2011 - Commentary
Creating high reliability in health care organizations.
Citation Text:
Pronovost P, Berenholtz SM, Goeschel CA, et al. Creating high reliability in health care organizations. Health Serv Res. 2006;41(4 Pt 2):1599-1617.
Copy Citation
Format:
Google Scholar PubMe…
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www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/speech-language-delay-screening-children-final-rec-bulletin-w-40th-annivlogo.pdf
January 23, 2024 - U.S. Preventive Services Task Force Issues Final Recommendation Statement on Screening for Speech and Language Delay and Disorders in Children: Task Force determines that more research is needed to recommend for or against screening all children age 5 years and younger
www.uspreventiveservicestaskforce.org 1
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integrationacademy.ahrq.gov/sites/default/files/2021-09/ibhc_atlas_framework_and_measures.pdf
January 01, 2021 - Atlas of Integrated Behavioral Health Care Quality Measures: Framework and Core Measures
Integration Framework and Associated Core Measures
This table is a printable summary of the Integration Framework and associated core measures found in the Atlas of Integrated Behavioral Health Care Quality
Measures (IBHC Measu…
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www.ahrq.gov/hai/cusp/modules/identify/alt-text.html
March 01, 2013 - Identify Defects Module Alternate Text
Slide Number and Title
Slide Content
Content for Alternative Text (Illustration)
Slide 1
Cover Slide
(CUSP Toolkit logo)
The "Identify Defects Through Sensemaking" module of the Comprehensive Unit-Based Safety Program (CUSP) Toolkit. The CUSP Toolk…
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psnet.ahrq.gov/node/612828/psn-pdf
February 23, 2022 - Delayed Diagnosis of Kidney Transplant Complications
February 23, 2022
Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
Objectives
Recognition, early evaluation, and management of kidney …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/surgical-complication-prevention/bim.docx
December 01, 2017 - Barrier Identification and Mitigation Tool
AHRQ Safety Program for Surgery
AHRQ Safety Program for Surgery
Barrier Identification and Mitigation Tool
Introduction
Problem Statement
Guidelines summarizing evidence exist to help ensure that patients receive recommended interventions. In addition, consistent guidel…
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www.ahrq.gov/hai/tools/surgery/tools/surgical-complication-prevention/bim.html
December 01, 2017 - Barrier Identification and Mitigation Tool
AHRQ Safety Program for Surgery
Introduction
Problem Statement
Guidelines summarizing evidence exist to help ensure that patients receive recommended interventions. In addition, consistent guideline adherence may significantly improve patient safety…
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psnet.ahrq.gov/node/46902/psn-pdf
August 20, 2018 - Researchers conducted interviews with 165 frontline staff and senior leaders working at three
academic … They found that leaders viewed formal systems for raising concerns
favorably, but other respondents
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psnet.ahrq.gov/node/40166/psn-pdf
April 03, 2017 - This set of articles offers a strategic framework for
leaders to address conflict as a key component … 2, the authors focus on designing a process for managing conflict and developing competencies for
leaders
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015096-davison-final-report-2008.pdf
January 01, 2008 - Hospital leaders
reported that this module had few problems. … TDH leaders thought that staff accepted the new systems
fairly well. … The gradual implementation process was perceived as useful by
most leaders. … All hospital leaders expressed frustration with this system. … TDH leaders should be proud of their accomplishments during this grant.
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psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
October 01, 2007 - The survey results were a wake-up call for the organization's leaders. … First, a small group of 10 key clinical and operational leaders attended a day-long session with David … The leaders who attended enthusiastically embraced the just culture concept, finding that it provides … Leaders must ask hard questions like, "How prevalent is this behavior? Why are people doing this? … Leaders must establish processes to know when someone is engaging in reckless behavior and be willing
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psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
June 01, 2003 - Developing these hospital staffing plans requires a complex dance involving nurse leaders, staff nurses … Accordingly, nurse leaders and their designees must develop strategies to deal with these absences to … It is the responsibility of the board of trustees and senior leaders to empower the Chief Nurse to design … Nurse unit leaders must anticipate changing staffing needs and assess at least 4-8 hours prior to the … As budgets tighten, it is vital that nurse leaders maintain RN ratios when census is high and decrease