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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840256/psn-pdf
    November 16, 2022 - This has been really interesting conversation; it has been really interesting to learn about your work

  2. AHRQ National Web Conference on the Role of Health IT to Improve Care Transitions - Q&As (pdf file)

    digital.ahrq.gov/sites/default/files/docs/care-transitions-qas-092619.pdf
    September 26, 2019 - AHRQ National Web Conference on the Role of Health IT to Improve Care Transitions - Q&As AHRQ National Web Conf…

  3. Development of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture: Slide Presentation (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/ascwebinar/smith2slides.pdf
    June 02, 2025 - Development of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture: Slide Presentation 12 12 Development of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture Scott Smith, PhD Senior Study Director 13 13 What is Patient Safety Culture? “The way we do things around he…

  4. Interview with the OPTIMA Project Team | Agency for Healthcare Research and Quality

    www.ahrq.gov/evidencenow/projects/urinary/optima-interview.html
    November 01, 2024 - Interview with the OPTIMA Project Team Project Overview: The Optimizing Primary Care Tools for Incontinence Management (OPTIMA) project, led by University of California San Diego, is implementing a four-pronged intervention to improve the quality of care for women with urinary incontinence (UI). This intervent…

  5. Toolkit for Reducing CAUTI in Hospital Units: Implementation Guide (pdf file)

    www.ahrq.gov/sites/default/files/publications/files/implementation-guide_0.pdf
    September 01, 2015 - Through use of the Learn From Defects tool, it provides a way to help analyze and reduce the risk of … prevails to a culture of safety—a learning environment in which errors are treated as an opportunity to learn … The 10 CUSP Toolkit modules are— • Learn About CUSP: Provides an overview of the CUSP model and resources … Implementing Change Learn From Defects Generate Short- Term Wins Challenge the Process Improve … Spread Learn From Defects Consolidate Gains and Produce More Change N/A When CAUTI prevention

  6. Toolkit for Reducing CAUTI in Hospital Units: Implementation Guide (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide.pdf
    September 01, 2015 - Through use of the Learn From Defects tool, it provides a way to help analyze and reduce the risk of … prevails to a culture of safety—a learning environment in which errors are treated as an opportunity to learn … The 10 CUSP Toolkit modules are— • Learn About CUSP: Provides an overview of the CUSP model and resources … Implementing Change Learn From Defects Generate Short- Term Wins Challenge the Process Improve … Spread Learn From Defects Consolidate Gains and Produce More Change N/A When CAUTI prevention

  7. Preventing CAUTI in the ICU Setting Facilitator’s Guide Transcript | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cauti-tools/facil-guide/preventing-cauti-icu-setting-transcript.html
    February 01, 2023 - Slide 10 So, what did you learn in this module? … Slide 11 So, what did you learn in this module?

  8. Implementation Guide: MRSA and SSI Prevention (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/147-implementation-guide.pdf
    April 01, 2025 - Please review the available program tools below to learn more about how each of these tools is set up … Learning From Defects Tool highlights Step 4 of the Comprehensive Unit-based Safety Program, which is to “learn

  9. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. | PSNet

    psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
    January 23, 2017 - Nurses learn the “ Five Rights of Medication Administration ” 25 but some experts propose that all providers … who administer medications should learn and abide by the “Nine Medication Administration Rights”. 26 … increase in the use of closed-loop communication. 42 Medication error reporting The safest organizations learn

  10. Final Progress Report: Medication Reconciliation: Bridging Communications Across the Continuum of Care (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/muller-report.pdf
    January 01, 2024 - Final Progress Report: Medication Reconciliation: Bridging Communications Across the Continuum of Care Title: Medication Reconciliation: Bridging Communications Across the Continuum of Care Principal Investigator and Team Members: Melinda Muller, MD, Lynn Belcher, RPh, Melissa Blanchard, MP, Amy Caster-Winegeart, …

  11. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
    February 26, 2025 - change their culture and how RCA could be changed to support this cultural change, which drew them to learn … must shift to support a psychologically safe environment where staff are encouraged to report and learn

  12. Improving Healthcare Through AHRQ's Digital Healthcare Research Program: 2023 Year in Review (pdf file)

    digital.ahrq.gov/sites/default/files/ahrq-dhr-2023-year-in-review.pdf
    January 01, 2023 - interoperable CDS resources so that developers, informaticists, and healthcare system leaders can learn … Learn more. … Learn more. … Learn more. LEARN MORE Want to know more? … Visit our website at https://digital.ahrq.gov/ to learn more about our team, current funding priorities

  13. Presentation: Program Overview

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/assess-psc-hsop-slides.pptx
    January 01, 2017 - Improving Care Educate staff on science of safety Identify defects Assign executive to adopt unit Learn

  14. Second Victim: Error, Guilt, Trauma, and Resilience. | PSNet

    psnet.ahrq.gov/issue/second-victim-error-guilt-trauma-and-resilience
    April 13, 2018 - January 22, 2014 Informal learning from error in hospitals: what do we learn, how do … we learn and how can informal learning be enhanced?

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33640/psn-pdf
    September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? … What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? … https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety- transformation … through each of these in greater https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation … https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation

  16. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.131_slideshow.ppt
    August 01, 2006 - Use your five senses….Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice

  17. Partnering with Patients to Disseminate Research Products (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/sadwin.pdf
    January 01, 2011 - § Push Hard and Fast in the Center Slide 15 Photograph: Photo of various chests with the words "Learn … Healthcare/Researchers Photograph: Image of 5 health care professionals, with the words 'Focus on Quality, Learn

  18. Research Summary | Digital Healthcare Research

    digital.ahrq.gov/2019-year-review/research-summary
    January 01, 2019 - Learn More   Key Research Findings The Digital Healthcare Research Program funds research to … Learn more about the impact and key findings here.

  19. Compensation of chief executive officers at nonprofit US hospitals. | PSNet

    psnet.ahrq.gov/issue/compensation-chief-executive-officers-nonprofit-us-hospitals
    December 18, 2018 - January 22, 2014 Informal learning from error in hospitals: what do we learn, how do … we learn and how can informal learning be enhanced?

  20. Employee / Staff Pre-Go-Live Expectations / Perceptions Clinical Information Systems Survey (pdf file)

    digital.ahrq.gov/sites/default/files/docs/survey/cis-survey-pre-go-live-physician.pdf
    December 27, 2004 - My ability to learn about and improve our patient care processes. [ ] [ ] [ ] [ ] [ ] [ ] … Sufficient resources have been provided for me to learn to use the new systems [ ] [ ] [ ] [ … My ability to learn about and improve our patient care processes. [ ] [ ] [ ] [ ] [ ] [ ] … Sufficient resources were provided for me to learn to use the new systems. [ ] [ ] [ ] [
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