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  1. First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit | PSNet

    psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
    October 30, 2019 - RW: What have you come to learn about the politics of trying to move the needle on the overall cost … it on as part of our responsibility to at least understand where the resources are around us; either learn … the information you need to learn or send people to the place you need to send them to.

  2. Suggested Timeline for Implementation (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/timeline-tasks.pdf
    June 01, 2021 - Suggested Timeline for Implementation Date Presentations and/or Narrated Presentations Supporting Materials Activities for the Stewardship Team Activities for Frontline Providers Week 1 The Four Moments of Antibiotic Decision Making: An Introduction to Improving Antibiotic Use i…

  3. Preventing CAUTI in the ICU Setting: Transcript (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-transcript.pdf
    September 01, 2015 - Slide 10 So, what did you learn in this module? … Slide 11 So, what did you learn in this module?

  4. Building Self-Empowered Teams for Improving Safety in Postoperative Pain Management (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Singh-R_68.pdf
    April 20, 2008 - Review and learn. Systemic learning from process evaluation (without assigning blame).

  5. Establishing a Safety Culture: Thinking Small | PSNet

    psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
    December 01, 2006 - complexity of the differential diagnostic process, and the need for residents to make some mistakes to learn … Implementing safety cultures in medicine: what we learn by watching physicians.

  6. Incorporating Patient-Reported Outcomes into Shared Decision Making with Patients with Osteoarthritis of the Knee - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/r21hs027037-bozic-final-report-2024.pdf
    January 01, 2024 - Incorporating Patient-Reported Outcomes into Shared Decision Making with Patients with Osteoarthritis of the Knee - Final Report TITLE PAGE Title of Project Incorporating Patient-Rep…

  7. Health Information Technology to Support Clinical Decision Making in Obesity Care - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/publication/r18hs018646-gance-cleveland-final-report-2014.pdf
    January 01, 2014 - Questions were asked to learn more about providers’ perspectives on barriers, facilitators, and impact

  8. Safety I, Safety II, and the New Views of Safety | PSNet

    psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
    October 02, 2024 - Nonetheless, because these events are frequent, if we can understand how and why they happen, we can learn … April 13, 2022 Using Safety-II and resilient healthcare principles to learn from Never Events.

  9. Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency Medicine Training Program in a Regional Health Care System Following the National Standard of Care (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Shah_99.pdf
    March 23, 2008 - [N (%)] 2 (12) 7 (41) 7 (41) 1 (6) 17 Confidential (used only to learn how to prevent future … Should hospital reports of adverse events be confidential and only used to learn how to prevent future … Should hospital reports of adverse events be confidential and only used to learn how to prevent future … 1 Confidential (only used to learn how to prevent future mistakes) 2 Also released to the public

  10. ARRA Delivery System Initiative | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/delivery-initiative/arragrantee-williams.html
    December 01, 2017 - ARRA Delivery System Initiative Presentations and Publications by Recipients of ARRA Delivery System Grants Bundled Episode Payment and Gainsharing Demonstration Project Principal Investigator: Tom Williams Robinson J. Purchaser Initiatives to Improve Value for Spine Surgery. Innovative Techniques in Spin…

  11. Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Mazur (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/3-unc-webcast-mazur.pdf
    June 02, 2025 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Mazur U N C H E A L T H C A R E S Y S T E M U N C H E A L T H C A R E Implementation of an Event Reporting and Learning System Leads to Improvements in Patient …

  12. University of California, Davis, Health CME/CEU Information | PSNet

    psnet.ahrq.gov/basic-page/ucd-cmeceu-trainee-certification
    November 01, 2019 - University of California, Davis, Health CME/CEU Information WebM&M Spotlight cases on AHRQ’s PSNet offer CME/CEU and Maintenance of Certification (MOC) credit.  Effective November 2019, each Spotlight Case and Commentary is certified for the AMA PRA Category 1 ™and maintenance of certification (MOC) through the Amer…

  13. Transformation to the Patient-Centered Medical Home in CareOregon Clinics | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/research-transform-primary-care/transform/profile/meenan.html
    October 01, 2015 - Transformation to the Patient-Centered Medical Home in CareOregon Clinics Principal Investigator: Richard T. Meenan, PhD, MPH, MBA Institution: Center for Health Research–Kaiser Permanente AHRQ Grant Number: R18 HS019146 Number and Type of Practices This project included Medicaid …

  14. The Contribution of Diagnostic Error to Maternal Mortality and Severe Maternal Morbidity | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-2.html
    September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science The Contribution of Diagnostic Error to Maternal Mortality and Severe Maternal Morbidity Previous Page Next Page Table of Contents The Contribution of Diagnostic Er…

  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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