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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-workplace-safety-resources.pdf
January 01, 2023 - cdctrain/course/1081802/ (requires free account setup and login)
This guide provides ideas and lessons learned
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psnet.ahrq.gov/node/846564/psn-pdf
March 29, 2023 - The authors also
presented evidence that it was cost-effective and detailed implementation lessons learned … psnet.ahrq.gov/issue/usability-human-factors-based-clinical-decision-support-emergency-department-lessons-learned
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/naa-october-2024-webinar-slides.pdf
January 01, 2024 - Based on what you have learned today,
What would you like to do differently or better
to improve the
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Learning From Defects: Applying the “Swiss cheese model” of System Failure
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
Slide Title and Commentary
Slide Number and Slide
Learning From Defects: Applying the “Swiss C…
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psnet.ahrq.gov/node/840255/psn-pdf
November 16, 2022 - Using Human Factors Engineering and the SEIPS Model
to Advance Patient Safety in Care Transitions
November 16, 2022
Carayon P, Werner N, Makkenchery A, et al. Using Human Factors Engineering and the SEIPS Model to
Advance Patient Safety in Care Transitions . PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspecti…
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/timeline-checklist-nc.pdf
April 01, 2018 - Heart Health NOW! Advancing Heart Health in NC Primary Care
Heart Health NOW!
Advancing Heart Health in NC Primary Care
Practice Participation Timeline and Checklist “CCNC PF” = Practice Facilitator; “AHEC PC” = Practice Coach
1) Practice Enrollment: To be completed during 1-2 in-person meetings, as n…
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www.ahrq.gov/research/findings/final-reports/index.html?page=3
January 01, 2024 - Grantee Final Reports: Patient Safety
Final reports from research grants administered since 2000 on a variety of patient safety topics, such as measure development, medication safety, and diagnostic safety.
The Agency for Healthcare Research and Quality Center for Quality Improvement and Patient Safety subdivis…
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www.ahrq.gov/research/findings/final-reports/index.html?page=1
January 01, 2024 - Grantee Final Reports: Patient Safety
Final reports from research grants administered since 2000 on a variety of patient safety topics, such as measure development, medication safety, and diagnostic safety.
The Agency for Healthcare Research and Quality Center for Quality Improvement and Patient Safety subdivis…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/engaging-champions.pdf
April 01, 2022 - Making It Work Tip Sheet: Engaging Physician Champions in Preventing CLABSI and CAUTI
AHRQ Safety Program for Intensive Care Units:
Preventing CLABSI and CAUTI
Making It Work Tip Sheet
Engaging Physician Champions in Preventing CLABSI and
CAUTI
This “Making It Work” tip sheet provides additional informa…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science-brief1.pdf
April 02, 2020 - Data Sources and Related Strategies for Measurement of Diagnostic Safety
Data Source
What Can Be
Learned
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science.pdf
April 02, 2020 - Data Sources and Related Strategies for Measurement of Diagnostic Safety
Data Source
What Can Be
Learned
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-transcript-508-compliant.pdf
June 01, 2017 - But I learned a lot. … I learned from the experience that big change is hard, and sometimes it takes a long time, and
it can … Are there any lessons learned in this area that you want to share
that perhaps can expedite the process … So what I've learned is, as I said, some
things take a lot of time.
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www.ahrq.gov/nursing-home/materials/leadership/index.html
June 01, 2022 - Leadership, Management, and Quality Improvement
Nursing home administrators and others may benefit from the following specific resources that address leadership and quality improvement.
Leadership and Management
Leading By Example Learning Module
This learning module offers ideas to help boost mora…
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www.ahrq.gov/nursing-home/learning-modules/support.html
December 01, 2022 - Emotional and Organizational Support for Staff series
This series of three learning modules features strategies to help nursing home teams recognize and manage stress, work together to tackle common challenges, and practice open communication.
Module 1: Identifying & Overcoming Anxiety
We all experience st…
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psnet.ahrq.gov/node/46980/psn-pdf
June 19, 2018 - Can first-year medical students acquire quality
improvement knowledge prior to substantial clinical
exposure? A mixed-methods evaluation of a pre-clerkship
curriculum that uses education as the context for
learning.
June 19, 2018
Brown A, Nidumolu A, Stanhope A, et al. Can first-year medical students acquire qual…
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psnet.ahrq.gov/node/867687/psn-pdf
March 05, 2025 - Simulation-debriefing enhanced needs assessment to
address quality markers in health care: an innovation for
prospective hazard analysis.
March 5, 2025
Barker LT, Bond WF, Willemsen-Dunlap AM, et al. Simulation-debriefing enhanced needs assessment to
address quality markers in health care: an innovation for prospe…
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psnet.ahrq.gov/node/44350/psn-pdf
July 29, 2015 - Reporting and using near-miss events to improve patient
safety in diverse primary care practices: a collaborative
approach to learning from our mistakes.
July 29, 2015
Crane S, Sloane PD, Elder NC, et al. Reporting and Using Near-miss Events to Improve Patient Safety in
Diverse Primary Care Practices: A Collaborat…
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psnet.ahrq.gov/node/43438/psn-pdf
February 23, 2018 - Safety-I and Safety-II: The Past and Future of Safety
Management.
February 23, 2018
Hollnagel E. Aldershot, Hampshire, England: Ashgate; 2014. ISBN: 9781472423085.
https://psnet.ahrq.gov/issue/safety-i-and-safety-ii-past-and-future-safety-management
Historically, the approach to patient safety has been more reacti…
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psnet.ahrq.gov/node/867446/psn-pdf
January 08, 2025 - Methodological approaches for analyzing medication
error reports in patient safety reporting systems: a
scoping review.
January 8, 2025
Tchijevitch O, Hansen SM-B, Hallas J, et al. Methodological approaches for analyzing medication error
reports in patient safety reporting systems: a scoping review. Jt Comm J Qual…
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psnet.ahrq.gov/node/60694/psn-pdf
January 01, 2021 - Reporting incidents involving the use of advanced
medical technologies by nurses in home care: a cross-
sectional survey and an analysis of registration data.
July 15, 2020
ten Haken I, Ben Allouch S, van Harten WH. Reporting incidents involving the use of advanced medical
technologies by nurses in home care: a cr…