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5441. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/844757/psn-pdf
      September 11, 2019 - Diagnostic overshadowing in dentistry. September 11, 2019 Clough S, Handley P. Diagnostic overshadowing in dentistry. Br Dent J. 2019;227(4):311-315. doi:10.1038/s41415-019-0623-x. https://psnet.ahrq.gov/issue/diagnostic-overshadowing-dentistry Assumptions, communication barriers, and implicit biases can compromis…

5442. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40729/psn-pdf
      October 04, 2011 - Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008. October 4, 2011 Cassidy CJ, Smith AF, Arnot-Smith J. Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning Syste…

5443. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60040/psn-pdf
      March 11, 2020 - Shifting the Mindset: A Closer Look at Hospital Complaints. March 11, 2020 Newcastle upon Tyne, UK: Healthwatch; January 2020. https://psnet.ahrq.gov/issue/shifting-mindset-closer-look-hospital-complaints Organizations need to do more than report and collect complaint data to realize improvements based on what is…

5444. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46401/psn-pdf
      September 13, 2017 - Understanding middle managers' influence in implementing patient safety culture. September 13, 2017 Gutberg J, Berta W. Understanding middle managers' influence in implementing patient safety culture. BMC Health Serv Res. 2017;17(1):582. doi:10.1186/s12913-017-2533-4. https://psnet.ahrq.gov/issue/understanding-mid…

5445. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837038/psn-pdf
      May 04, 2022 - Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS. May 4, 2022 London UK: Patient Safety Learning: 2022. https://psnet.ahrq.gov/issue/mind-implementation-gap-persistence-avoidable-harm-nhs Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financi…

5446. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46787/psn-pdf
      October 15, 2018 - Institute for Safe Medication Practices International Mentorship Program. October 15, 2018 Institute for Safe Medication Practices. https://psnet.ahrq.gov/issue/institute-safe-medication-practices-international-mentorship-program Structured interaction with a wide variety of experts and environments enables medica…

5447. Practice and Quality Improvement | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/reports/2025-annual-report/quality-improvement.html
      August 01, 2025 - AHRQ’s Investments in Primary Care Research for 2023 and 2024 Practice and Quality Improvement Previous Page Next Page Table of Contents AHRQ’s Investments in Primary Care Research for 2023 and 2024 Acknowledgements and Authors Message from the Director of AHRQ’s National Center for Excellence…

5448. Scisafetynotes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
      June 02, 2025 - SAY: The “Understand the Science of Safety” module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit discusses the importance of understanding system design, safe design principles, and valuing diverse input from team members. By analyzing patient safety as a science, frontline providers will provide a h…

5449. Making It Work Tip Sheet: Overcoming the Just in Case Mindset (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/just-in-case-mindset.pdf
      April 01, 2022 - Making It Work Tip Sheet: Overcoming the Just in Case Mindset AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI Making It Work Tip Sheet Overcoming the “Just in Case” Mindset The "Making It Work" tip sheet provides additional information to help intensive care unit (ICU) te…

5450. Tools for Sustainability: Premortem and Scorecard: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/sustainability/premortem-scorecard-slides.html
      February 01, 2017 - Tools for Sustainability: Premortem and Scorecard: Slide Presentation AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients Tools for Sustainability: Premortem and Scorecard Slide 2: Learning Objectives After this session, you will…

5451. How CUSP Enables Nurse Empowerment (Slide Presentation) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/nurse-empower/slides.html
      October 01, 2014 - How CUSP Enables Nurse Empowerment (Slide Presentation) On the CUSP: Stop BSI This PowerPoint slide presentation was shown on November 15, 2011. Contents Slide 1. How CUSP Enables Nurse Empowerment Slide 2. Presenters (continued) Slide 3. CUSP Components Slide 4. How is CUSP Different? It Empowers N…

5452. Leadership To Improve Diagnosis: A Call to Action - Issue Brief 5 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dx-leadership.pdf
      June 03, 2021 - Leadership To Improve Diagnosis: A Call to Action - Issue Brief 5 PATIENT SAFETY e Issue Brief 5 Leadership To Improve Diagnosis: A Call to Action e Issue Brief 5 Leadership To Improve Diagnosis: A Call to Action Prepared for: Agency for Healthcare Research and Quality 5600 Fishers Lane Rockville, …

5453. Leadership To Improve Diagnosis: A Call to Action - Issue Brief 5 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dx-leadership-cx.pdf
      June 03, 2021 - Leadership To Improve Diagnosis: A Call to Action - Issue Brief 5 PATIENT SAFETY e Issue Brief 5 Leadership To Improve Diagnosis: A Call to Action e Issue Brief 5 Leadership To Improve Diagnosis: A Call to Action Prepared for: Agency for Healthcare Research and Quality 5600 Fishers Lane Rockville, M…

5454. RFA-HS-23-012: Implementing and Evaluating New Models for Delivering Comprehensive, Coordinated, Person-Centered Care to People with Long COVID (U18) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/long-covid/faqs-long-covid.pdf
      June 02, 2025 - RFA-HS-23-012: Implementing and Evaluating New Models for Delivering Comprehensive, Coordinated, Person-Centered Care to People with Long COVID (U18) RFA-HS-23-012: Implementing and Evaluating New Models for Delivering Comprehensive, Coordinated, Person-Centered Care to People with Long COVID (U18) Frequentl…

5455. 025-Assessing-Evc-Webinar-Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/025-assessing-evc-webinar-notes.docx
      October 01, 2024 - After the team learned about the process, the program was piloted on one floor with support from the

5456. 103-How-To-Integrate-Cusp-Approach-Periop-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/103-how-to-integrate-cusp-approach-periop-fg.docx
      April 01, 2025 - CUSP happens with others, not by others, and improvements learned locally should be shared broadly.

5457. Curated Article Libraries | PSNet
      psnet.ahrq.gov/curated-article-libraries
      March 18, 2025 - Curated Libraries Curated Libraries are groupings of PSNet content, curated by AHRQ and by other experts in the patient safety field. Watch the video to learn more about how this new feature works and how it can be of benefit to you. Latest PSNet…

5458. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? | PSNet
      psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
      June 24, 2020 - SPOTLIGHT CASE Fatal Error in Neonate: Does "Just Culture" Provide an Answer? Citation Text: Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. …

5459. Improving the Value of Patient Safety Reporting Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
      June 12, 2008 - safety reporting systems will not provide the answer.28 One measure of safety could be whether we learned

5460. 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 - Prevention is a guidance document that shares tips on recognizing success and sharing the lessons learned … CUSP teams have a unique opportunity to collaborate with other departments to share the lessons learned