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digital.ahrq.gov/sites/default/files/docs/citation/r21hs024750-sherwin-final-report-2019.pdf
January 01, 2019 - The ultimate performance was moderate, however many valuable lessons were learned
during its development … Several valuable lessons were learned during the development of ISA.
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www.ahrq.gov/sites/default/files/2025-03/prabhakaran-holl-report.pdf
January 01, 2025 - Final Progress Report: Enhancing Stroke Prehospital and Emergency Evaluation and Delivery
1. Title Page
Project Title Enhancing Stroke Prehospital and Emergency Evaluation and Delivery
MPIs Shyam Prabhakaran, MD, MS, and Jane L. Holl, MD, MPH
Organization University of Chicago
Dates of the Project 07/01/2018 - 04/30…
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psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
October 02, 2024 - Safety I, Safety II, and the New Views of Safety
Citation Text:
Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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Format:
Google Scholar BibTeX E…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/fac-notes.html
October 01, 2020 - Several critical success factors are required to sustain the interventions learned and continued gains … The following examples will provide “lessons learned” to assist in sustainability in your facility.
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psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
February 26, 2025 - We have learned that there might be underexplored sources of reliability. … I recently learned of a nursing unit that has embedded sensitivity to operations in an interesting way
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psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
February 26, 2025 - We have learned that there might be underexplored sources of reliability. … I recently learned of a nursing unit that has embedded sensitivity to operations in an interesting way
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/snac-final-report-mar2023.pdf
January 01, 2025 - Subcommittee of the
National Advisory Council:
Informing the National
Action Alliance to Advance
Patient and Workforce
Safety
Final Report: December 19, 2023
Submitted by:
Lucy A. Savitz, Ph.D., MBA on behalf of the AHRQ Subcommittee
Subcommittee of the AHRQ National Advisory Cou…
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psnet.ahrq.gov/issue/application-system-dynamics-modelling-system-safety-improvement-present-use-and-future
October 27, 2021 - Review
Emerging Classic
The application of system dynamics modelling to system safety improvement: present use and future potential.
Citation Text:
The application of system dynamics modelling to system safety improvement: present use and future potential. Ibrah…
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/114-tenn-heart-health-newsletter.pdf
November 01, 2021 - Tennessee Heart Health Network Newsletter, November 2021
Tennessee Heart Health Network Newsletter November 2021
1/4
View this email in your browser
Welcome to Tennessee Heart Health Network!
We are a partnership committed to improving the health of Tennesseans with or at risk for
cardiovascular disease. Tenness…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/nh-workplace-safety-ginsberg.pdf
January 01, 2015 - New AHRQ SOPS® Workplace Safety Supplemental Item Set for Nursing Homes - Caren Ginsberg, Ph.D.
5
AHRQ’s Surveys on Patient Safety Culture™
(SOPS®) Program
Caren Ginsberg, Ph.D.
Center for Quality Improvement and Patient Safety, AHRQ
6
Agency for Healthcare Research and Quality
• AHRQ is:
► A research and sci…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-new-sops-workplace-safety-mcgaffigan.pdf
December 01, 2020 - New AHRQ SOPS® Workplace Safety Supplemental Items for Hospitals - McGaffigan
Workforce
Safety
Patricia McGaffigan, RN, MS, CPPS
pmcgaffigan@ihi.org; @Pmcgaffigan_IHI
mailto:pmcgaffigan@ihi.org
Why Workforce Safety Matters
Workforce safety is
essential for safe, high-
quality care and is
preconditional to …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/training-tools/training-tools-material-guide.docx
May 01, 2017 - Overview
Definition of Sustainability and its Importance in Quality Improvement
· Slides 4-8
Linking Sustainability and Spread
· Slides 9-10
Planning Early for Sustainability
· Slides 11-12
Barriers and Solutions to Sustaining Improvements
· Slides 13-17
Steps to Creating and Implementing a Sustainability Plan
· Slides…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/131-what-are-the-4-es-one-pager.docx
May 24, 2024 - The aim is to Engage hearts and minds and thus, change attitudes and behaviors.1-6
Raise awareness of the problem, communicate benefits of the solution, and lay out the goals for the intervention.
· Use unit data, published literature, and national benchmarks. Storytelling is an underrated tool.
Engagement is not a on…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/aseptic-catheter-insertion-practices-ed.pptx
June 02, 2025 - PowerPoint Presentation
Aseptic catheter insertion practices in the ED: A Focus on Engagement
Milisa Manojlovich PhD, RN, CCRN
Associate Professor
University of Michigan, School of Nursing
1
1
Learning Objectives
Discuss barriers to ED staff engagement
Describe strategies to engage ED staff in aseptic ins…
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www.ahrq.gov/funding/grantee-profiles/grtprofile-mchugh.html
May 01, 2025 - Grantee Profile
Improving Heart Health in Manufacturing Communities
Megan McHugh, Ph.D. Professor of Emergency Medicine Feinberg School of Medicine Northwestern University “Manufacturing workers have historically earned higher wages than similar workers in other industries and are more likely to be offered …
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www.ahrq.gov/funding/grantee-profiles/grtprofile-vogelmeier.html
December 01, 2023 - Grantee Profile
Improving Guidelines for Nursing Home-Associated Viral Respiratory Infections
Amy Vogelsmeier, Ph.D., R.N., FAAN.
Associate Professor
Sinclair School of Nursing
University of Missouri–Colombia
Amy Vogelsmeier,
Ph.D., R.N., FAAN
“AHRQ as a funding agency has provided an imp…
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psnet.ahrq.gov/issue/investigating-improvement-five-strategies-ensure-national-patient-safety-investigations
February 28, 2024 - Commentary
Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety.
Citation Text:
Macrae C. Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety. J R Soc Med.…
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psnet.ahrq.gov/issue/evaluation-interprofessional-team-training-program-improve-use-patient-safety-strategies
May 18, 2022 - Study
Evaluation of an interprofessional team training program to improve the use of patient safety strategies among healthcare professions students.
Citation Text:
Evaluation of an interprofessional team training program to improve the use of patient safety strategies among healthcare p…
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psnet.ahrq.gov/issue/nursing-accreditation-system-and-patient-safety
September 23, 2009 - Study
Nursing accreditation system and patient safety.
Citation Text:
Teng C-I, Shyu Y-IL, Dai Y-T, et al. Nursing accreditation system and patient safety. J Nurs Manag. 2012;20(3):311-8. doi:10.1111/j.1365-2834.2011.01287.x.
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DOI Google Scholar PubMe…
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psnet.ahrq.gov/issue/systems-analysis-critical-incidents-london-protocol
April 06, 2016 - Book/Report
Systems Analysis of Critical Incidents: the London Protocol.
Citation Text:
Systems Analysis of Critical Incidents: the London Protocol. Taylor-Adams S, Vincent C. London, UK: NIHR North West London Patient Safety Research Collaboration, Imperial College London; 2024.
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