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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - participants noted the critical importance of having a diversity of voices available to discuss and learn
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/financial-sustainability
January 01, 2019 - Investigate the relevant policies of each of the payers for your patient mix and learn what and how much
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psnet.ahrq.gov/node/33701/psn-pdf
October 01, 2010 - actually perform the task, not how the task is prescribed to be
performed.(12) Over time, workers often learn
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psnet.ahrq.gov/node/38225/psn-pdf
February 16, 2011 - Changing conversations: teaching safety and quality in
residency training.
February 16, 2011
Voss JD, May NB, Schorling JB, et al. Changing conversations: teaching safety and quality in residency
training. Acad Med. 2008;83(11):1080-7. doi:10.1097/ACM.0b013e31818927f8.
https://psnet.ahrq.gov/issue/changing-convers…
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psnet.ahrq.gov/node/856640/psn-pdf
November 29, 2023 - Research from webAIRS incident reporting system.
November 29, 2023
Anaesth Intensive Care. 2023;51(6):372-421.
https://psnet.ahrq.gov/issue/research-webairs-incident-reporting-system
Centralized de-identified reports of patient safety events serve a core purpose for learning and
improvement. This article collectio…
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psnet.ahrq.gov/node/47936/psn-pdf
June 14, 2019 - A team disclosure of error educational activity: objective
outcomes.
June 14, 2019
Krumwiede KH, Wagner JM, Kirk LM, et al. A Team Disclosure of Error Educational Activity: Objective
Outcomes. J Am Geriatr Soc. 2019;67(6):1273-1277. doi:10.1111/jgs.15883.
https://psnet.ahrq.gov/issue/team-disclosure-error-educatio…
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psnet.ahrq.gov/node/47387/psn-pdf
September 12, 2018 - Guideline implementation: team communication.
September 12, 2018
Link T. Guideline Implementation: Team Communication: 1.8 www.aornjournal.org/content/cme. AORN J.
2018;108(2):165-177. doi:10.1002/aorn.12300.
https://psnet.ahrq.gov/issue/guideline-implementation-team-communication
Although team development has rec…
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www.ahrq.gov/nursing-home/resources/module-1-infection-prevention.html
April 01, 2022 - Module 1 Infection Prevention and Control Program—Nursing Home Infection Preventionist Training Course
Resource: Module 1 Infection Prevention and Control Program—Nursing Home Infection Preventionist Training Course
This module provides an overview of infection prevention and control programs and how to imp…
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www.ahrq.gov/nursing-home/resources/module-11a-reprocessing-equipment.html
May 01, 2022 - Module 11A—Reprocessing Reusable Resident Care Equipment—Nursing Home Infection Preventionist Training Course
Resource: Module 11A—Reprocessing Reusable Resident Care Equipment—Nursing Home Infection Preventionist Training Course
This module discusses recommended practices for reprocessing reusable resident…
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www.ahrq.gov/action-alliance/webinars/implementing-cms-measure.html
June 01, 2025 - Implementing CMS’ Patient Safety Structural Measure
On May 13, 2025, leaders in patient safety structural measure (PSSM) implementation discussed some of the tools and resources that support implementation of the five domains of the PSSM: Leadership Commitment; Strategic Planning and Organizational Policy; Cult…
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/building-capacity/EvidenceNOW-BSC-overall-structure.pdf
June 02, 2025 - EvidenceNOW: Building State Capacity to Advance Equity in Heart Health
EvidenceNOW: Building State Capacity to
Advance Equity in Heart Health
State-Level Cooperative
MEDICAID &
OTHER PAYERS
RESEARCH
INSTITUTIONS
COMMUNITY
ORGANIZATIONS
PRIMARY CARE
ORGANIZATIONS
OTHER KEY
STAKEHOLDERS
QUALITY
IMPROVEMENT
O…
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psnet.ahrq.gov/node/38036/psn-pdf
January 02, 2017 - Debriefing medical teams: 12 evidence-based best
practices and tips.
January 2, 2017
Salas E, Klein C, King HB, et al. Debriefing medical teams: 12 evidence-based best practices and tips. Jt
Comm J Qual Patient Saf. 2008;34(9):518-527.
https://psnet.ahrq.gov/issue/debriefing-medical-teams-12-evidence-based-best-pr…
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psnet.ahrq.gov/node/43569/psn-pdf
April 25, 2016 - The safe day call: reducing silos in health care through
frontline risk assessment.
April 25, 2016
Paterson C, Miller K, Benden M, et al. The Safe Day Call: Reducing Silos in Health Care Through Frontline
Risk Assessment. Jt Comm J Qual Patient Saf. 2014;40(10):476-481.
https://psnet.ahrq.gov/issue/safe-day-call-r…
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psnet.ahrq.gov/node/43552/psn-pdf
December 16, 2014 - Robotic-assisted surgery: focus on training and
credentialing.
December 16, 2014
Dubeck D. PA-PSRS Patient Saf Advis. September 2014;11:93-101.
https://psnet.ahrq.gov/issue/robotic-assisted-surgery-focus-training-and-credentialing
Research has documented a substantial learning curve for surgeons as they develop sk…
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psnet.ahrq.gov/node/60956/psn-pdf
September 30, 2020 - Assessing and supporting late career practitioners: four
key questions.
September 30, 2020
White AA, Sage WM, Mazor KM, et al. Assessing and supporting late career practitioners: four key
questions. Jt Comm J Qual Patient Saf. 2020;46(10):591-595. doi:10.1016/j.jcjq.2020.07.001.
https://psnet.ahrq.gov/issue/assess…
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psnet.ahrq.gov/node/47244/psn-pdf
August 01, 2018 - The Second Society for Simulation in Healthcare
Research Summit: Beyond Our Boundaries.
August 1, 2018
Simul Healthc. 2018;13(3S suppl 1):S1-S55.
https://psnet.ahrq.gov/issue/second-society-simulation-healthcare-research-summit-beyond-our-boundaries
Simulation strategies can help examine team interaction and care …
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psnet.ahrq.gov/node/837982/psn-pdf
August 31, 2022 - Patient Safety Incident Response Framework.
August 31, 2022
London, England: NHS England; August 2022.
https://psnet.ahrq.gov/issue/patient-safety-incident-response-framework
Effective response to medical error requires a comprehensive systemic and process-focused incident
examination approach to ensure organizati…
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psnet.ahrq.gov/node/44551/psn-pdf
September 30, 2015 - Safety culture includes "good catches."
September 30, 2015
Traynor K. Safety culture includes "good catches". Am J Health Syst Pharm. 2015;72(19):1597-1599.
doi:10.2146/news150065.
https://psnet.ahrq.gov/issue/safety-culture-includes-good-catches
Near misses can provide opportunities for learning if there is a pro…
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psnet.ahrq.gov/node/836762/psn-pdf
March 16, 2022 - Physician liability in the age of data reliance and errors.
March 16, 2022
Montesantos L. Ann Health Law Life Sci. 2022;31(Spring):179-215.
https://psnet.ahrq.gov/issue/physician-liability-age-data-reliance-and-errors
Health information technologies (HIT) and advanced learning systems, if poorly designed, used,
ma…
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psnet.ahrq.gov/node/74019/psn-pdf
July 11, 2023 - PACT Collaborative: Pathway to Accountability,
Compassion and Transparency.
July 11, 2023
Ariadne Labs, Brigham and Women’s Hospital, Harvard TH Chan School of Public Health.
https://psnet.ahrq.gov/issue/pact-collaborative-pathway-accountability-compassion-and-transparency
Communication and Resolution Programs (CR…