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  1. 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
  2. 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
  3. Psn-Pdf (pdf file)

    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
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. 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…
  9. 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…
  10. 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…
  11. 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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    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 …
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…