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  1. Trauma-Informed Organizational Change Manual | Agency for Healthcare Research and Quality

    www.ahrq.gov/nursing-home/resources/trauma-informed.html
    May 01, 2021 - Trauma-Informed Organizational Change Manual Resource: Trauma-Informed Organizational Change Manual This manual guides organizations and systems in planning for, implementing and sustaining a trauma-informed organizational change. This manual provides a step-by-step guide with tools intended for anyone inte…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37638/psn-pdf
    May 24, 2015 - Work hours regulations for house staff in psychiatry: bad or good for residency training? May 24, 2015 Rasminsky S, Lomonaco A, Auchincloss E. Work Hours Regulations for House Staff in Psychiatry: Bad or Good for Residency Training? Academic Psychiatry. 2008;32(1). doi:10.1176/appi.ap.32.1.54. https://psnet.ahrq.g…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34783/psn-pdf
    March 28, 2005 - The organizational and intraorganizational development of disasters. March 28, 2005 Turner BA. The Organizational and Interorganizational Development of Disasters. Adm Sci Q. 1976;21(3):378. doi:10.2307/2391850. https://psnet.ahrq.gov/issue/organizational-and-intraorganizational-development-disasters This article…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40582/psn-pdf
    July 06, 2011 - Patient safety climate among orthopaedic surgery residents. July 6, 2011 Kadzielski J, McCormick F, Zurakowski D, et al. Patient safety climate among orthopaedic surgery residents. J Bone Joint Surg Am. 2011;93(11):e62. doi:10.2106/JBJS.J.01478. https://psnet.ahrq.gov/issue/patient-safety-climate-among-orthopaedic…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34782/psn-pdf
    November 01, 2016 - When systems fail. November 1, 2016 Roberts KH, Bea RG. When systems fail. Organ Dyn. 2002;29(3):179-191. doi:10.1016/s0090- 2616(01)00025-0. https://psnet.ahrq.gov/issue/when-systems-fail This review provides a detailed account of managerial causes of failure and managerial failure prevention strategies. The aut…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838184/psn-pdf
    September 28, 2022 - The hidden risk of wheelchair use. September 28, 2022 Quesenberry M. The hidden risk of wheelchair use. Patient Safety. 2022;4(3):6-9. doi:10.33940/alert/2022.9.1. https://psnet.ahrq.gov/issue/hidden-risk-wheelchair-use Medical devices intended to improve patient safety can unintentionally lead to patient harm. Th…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60928/psn-pdf
    September 16, 2020 - The risks of the prescribing cascade. September 16, 2020 Brody JE. The risks of the prescribing cascade. New York Times. 2020. https://psnet.ahrq.gov/issue/risks-prescribing-cascade Inappropriate care activities can cascade to significantly impact patient safety. This article shares how medication side effects can…

  8. Medical Mistakes and What Doctors Can Learn From Pilots | PSNet

    psnet.ahrq.gov/training-catalog/medical-mistakes-and-what-doctors-can-learn-pilots
    July 21, 2025 - Medical Mistakes and What Doctors Can Learn From Pilots Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Organization: Organization American Academy of Ophthalmology Even…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44481/psn-pdf
    September 09, 2015 - When doctors get it wrong: misdiagnoses are getting a closer look. September 9, 2015 Olsen J. Star Tribune. August 30, 2015. https://psnet.ahrq.gov/issue/when-doctors-get-it-wrong-misdiagnoses-are-getting-closer-look Diagnostic error is garnering increased attention as a patient safety problem. This news article r…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39683/psn-pdf
    June 08, 2011 - Surgical team training: promoting high reliability with nontechnical skills. June 8, 2011 Paige JT. Surgical team training: promoting high reliability with nontechnical skills. Surg Clin North Am. 2010;90(3):569-81. doi:10.1016/j.suc.2010.02.007. https://psnet.ahrq.gov/issue/surgical-team-training-promoting-high-r…

  11. Infographic - State Variations in Inpatient Stays for Substance Use Disorders (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/sud-inpatient-stays.pdf
    January 01, 2016 - Infographic - State Variations in Inpatient Stays for Substance Use Disorders AH State-level Rate of Inpatient Stays During 2016-2018 Alcohol-Related Disorders Opioid-Related Disorders 37.7 227.8 per 100,000 per 100,000 2.6 81.3 per 100,000 per 100,000 Across 38 States Source: AHRQ, Healthcare Cost a…

  12. Infographic - State Variations in Inpatient Stays for Substance Use Disorders (pdf file)

    hcup-us.ahrq.gov/reports/infographics/289_sud-inpatient-stays.pdf
    January 01, 2016 - Infographic - State Variations in Inpatient Stays for Substance Use Disorders AH State-level Rate of Inpatient Stays During 2016-2018 Alcohol-Related Disorders Opioid-Related Disorders 37.7 227.8 per 100,000 per 100,000 2.6 81.3 per 100,000 per 100,000 Across 38 States Source: AHRQ, Healthcare Cost a…

  13. How did CHIPRA quality demonstration States employ learning collaboratives to improve children’s health care quality? | Agency for Healthcare Research and Quality

    www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight13.html
    June 01, 2015 - Figures 1 , 2 , and 3 suggest that learning collaboratives can support practice improvement that leads

  14. Chapter 2. ST-PRA Development | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/final-reports/stpra/stpra2.html
    April 01, 2018 - This process leads to a probability of occurrence of the top-level event, along with the major risk points

  15. Lessons from the Field: Identifying Measurement Challenges and Successes (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/lessons/lessons-challenges-successes.pdf
    January 01, 2019 - Lessons from the Field: Identifying Measurement Challenges and Successes Lessons from the Field: Identifying Measurement Challenges and Successes Prepared for the Agency for Healthcare Research and Quality by L&M Policy Research, LLC with guidance from the Pediatric Quality Measure Program (PQMP) Grantees …

  16. Advancing Patient Safety Through Diagnostic Excellence (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/action-alliance-diagnostic-excellence-webinar.pdf
    June 01, 2025 - Advancing Patient Safety Through Diagnostic Excellence Advancing Patient Safety Through Diagnostic Excellence NATIONAL WEBINAR SERIES September 17, 2024 Housekeeping Instructions • This webinar will be recorded and available for viewing on the NAA website • Please use the ‘Chat’ function to engage with us thro…

  17. In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet

    psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
    September 24, 2024 - In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement Carole Stockmeier, Sarah Mossburg, Lee Merton | September 24, 2024  Also Read the Essay View more articles from the same authors. …

  18. Comorbidities Associated With Adult Inpatient Stays, 2019 (pdf file)

    hcup-us.ahrq.gov/reports/statbriefs/sb303-Comorbidities-Adult-Hospitalizations-2019.pdf
    January 01, 2019 - Comorbidities Associated With Adult Inpatient Stays, 2019 1 STATISTICAL BRIEF #303 December 2022 Pamela L. Owens, Ph.D., Lan Liang, Ph.D., Marguerite L. Barrett, M.S., and Kathryn R. Fingar, Ph.D., M.P.H. Introduction Most inpatient stays are complicated by one or more comorbidities …

  19. In Conversation with... Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace | PSNet

    psnet.ahrq.gov/perspective/conversation-cheryl-jones-about-addressing-workplace-violence-and-creating-safer
    October 31, 2023 - In Conversation with... Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace Cheryl B. Jones, PhD, RN, FAAN | October 31, 2023  Also Read the Essay View more articles from the same authors. Citation Text: Jones CB. In Conversation with…

  20. Addressing Workplace Violence and Creating a Safer Workplace | PSNet

    psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
    October 31, 2023 - Addressing Workplace Violence and Creating a Safer Workplace Cheryl B. Jones, PhD, RN, FAAN; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | October 31, 2023  Also Read the Conversation View more articles from the same authors. Citation Text: Jones CB, Sousane Z…
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