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psnet.ahrq.gov/node/47457/psn-pdf
January 17, 2019 - Developing a reporting culture: learning from close calls
and hazardous conditions.
January 17, 2019
Developing a reporting culture: Learning from close calls and hazardous conditions. Sentinel Event Alert.
2018;(60):1-8.
https://psnet.ahrq.gov/issue/developing-reporting-culture-learning-close-calls-and-hazardous-…
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psnet.ahrq.gov/node/37114/psn-pdf
October 04, 2011 - A descriptive study of morbidity and mortality
conferences and their conformity to medical incident
analysis models: results of the morbidity and mortality
conference improvement study, phase 1.
October 4, 2011
Aboumatar HJ, Blackledge CG, Dickson C, et al. A descriptive study of morbidity and mortality conference…
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psnet.ahrq.gov/node/39063/psn-pdf
December 17, 2009 - Safety and risk management interventions in hospitals: a
systematic review of the literature.
December 17, 2009
Dückers M, Faber M, Cruijsberg J, et al. Safety and risk management interventions in hospitals: a
systematic review of the literature. Med Care Res Rev. 2009;66(6 Suppl):90S-119S.
doi:10.1177/10775587093…
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www.ahrq.gov/hai/cusp/modules/nursing/alt-text.html
April 01, 2013 - “Role of the Nurse Manager” Slide Content and Alternative Text
Slide Number and Title
Slide Content
Content for Alternative Text (Illustration)
Slide 1
Title Slide
(CUSP logo)
The “Role of the Nurse Manager” module of the Comprehensive Unit-based Safety Program (CUSP) Toolkit. The CUSP t…
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psnet.ahrq.gov/primer/simulation-training
September 15, 2024 - Maternal Safety
January 31, 2024
Quality improvement lessons learned
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www.ahrq.gov/pcor/at-a-glance/index.html
October 01, 2024 - PCOR Trust Fund Investments At-A-Glance
Patient-centered outcomes research (PCOR) provides decision-makers with objective, scientific evidence on the comparative effectiveness of treatments, services, and other interventions used in healthcare. The Patient-Centered Outcomes Research Trust Fund (PCORTF) is funde…
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www.ahrq.gov/policymakers/chipra/demoeval/demostates/ma.html
March 01, 2019 - State at a Glance: Massachusetts
Learn more about the CHIPRA quality demonstration projects being implemented in Massachusetts.
Massachusetts is featured in the following reports:
Evaluation Highlight No. 1: How are CHIPRA demonstration States approaching practice-level quality measurement and what are t…
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psnet.ahrq.gov/node/35932/psn-pdf
October 03, 2017 - authors discuss a high-profile clinical trial incident and how transparency and sharing of lessons
learned
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www.ahrq.gov/sites/default/files/publications/files/sustainability-guide_2.pdf
September 01, 2015 - A Model for Sustaining and Spreading Safety Interventions: AHRQ Safety Program for Reducing CAUTI in Hospitals
A Model for Sustaining and Spreading
Safety Interventions
Contents
Background and Acknowledgments ............................................................................................... 2
How T…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/guides/sustainability-guide.pdf
September 01, 2015 - A Model for Sustaining and Spreading Safety Interventions: AHRQ Safety Program for Reducing CAUTI in Hospitals
A Model for Sustaining and Spreading
Safety Interventions
Contents
Background and Acknowledgments ............................................................................................... 2
How T…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
May 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Fatal Error in Neonate: Does ‘Just Culture’ Provide an Answer?
*
*
Source and Credits
This presentation is based on the May 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Sidney W.A. Dekker, Ph…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apa_breathing.pdf
June 02, 2025 - NICU Toolkit, Appendix A, How Can I Manage My Child’s Breathing Problems?
How Can I Manage My Child’s Breathing
Problems at Home?
■ Visit the NICU often, and help care
for your baby as much as possible in
the hospital.
■ Learn how to use equipment: pulse
oximeter, oxygen tank, nasal canula.
■ Know the signs…
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digital.ahrq.gov/ahrq-funded-projects/enhanced-handoffs-echo/citation/machine
January 01, 2024 - Machine learning-augmented interventions in perioperative care: A systematic review and meta-analysis.
Citation
Mehta D, Gonzalez XT, Huang G, Abraham J. Machine learning-augmented interventions in perioperative care: A systematic review and meta-analysis. Br J Anaesth. 2024 Dec;133(6):1159-1172. doi:…
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digital.ahrq.gov/ahrq-funded-projects/enhancing-patient-matching-support-operational-health-information-exchange/citation/machine
January 01, 2023 - Machine learning approaches to identify nicknames from a statewide Health Information Exchange.
Citation
Kasthurirathne SN, Grannis SJ. Machine learning approaches to identify nicknames from a statewide Health Information Exchange. AMIA Jt Summits Transl Sci Proc. 2019 May 6;2019:639-647. PMID: 312590…
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psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
March 01, 2013 - Years ago, physicians (and I'm sure this is true for nurses too) learned to be "it" in part at charity … However, much remains to be learned about how to optimally implement simulation-based education.
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digital.ahrq.gov/sites/default/files/docs/publication/PreventiveCareHandbook_062912comp.pdf
June 01, 2012 - An Interactive Preventive Care Record
c
An Interactive Preventive Care Record
Agency for Healthcare Research and Quality
Advancing Excellence in Health Care www.ahrq.gov
A Handbook for Using Patient-Centered Personal Health Records
To Promote Prevention
HEALTH IT
An Interactive Preventive Care Record
…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/demostates/mestateataglance.pdf
March 01, 2012 - Maine State at a Glance
…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/demostates/mdstateataglance.pdf
March 01, 2012 - Maryland State at a Glance
…
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www.ahrq.gov/sites/default/files/wysiwyg/talkingquality/resources/checklist/checklist-promote-report.doc
December 26, 2018 - Disseminate Complete Checklist
Note: You must use the UP and DOWN ARROW instead of TAB or SHIFT + TAB to fill out this form. This document contains twenty-two links.
TalkingQuality
Your Project Checklist:
Promote Your Health Care Quality Report to Consumers
This document contains checklists for the following sectio…
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psnet.ahrq.gov/issue/learning-patient-safety-incidents-involving-acutely-sick-adults-hospital-assessment-units
November 11, 2020 - Study
Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement.
Citation Text:
Urquhart A, Yardley S, Thomas E, et al. Learning from patient safety incidents involving acutely …