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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Learning From Defects in Care of Mechanically Ventilated Patients
SAY:
In this module, we will discuss the Learning From Defects tool. It is a very useful process that enables frontline staff to ident…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/sustainability/premortem-scorecard-facguide.docx
January 01, 2017 - Facilitator Guide: Tools for Sustainability: Premortem and Scorecard
Slide Title and Commentary
Slide Number and Slide
Tools for Sustainability: Premortem and Scorecard
SAY:
This module will cover sustaining and spreading safety improvements. To preface the sustainability discussions, this module is designed to…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/Translation-Guidelines-SOPS-090222.pdf
September 02, 2022 - Translation Guidelines for the AHRQ Surveys on Patient Safety Culture™ (SOPS®)
Guidelines for Translating SOPS® Surveys - Updated 9/2/2022
1
Translation Guidelines for the AHRQ Surveys
on Patient Safety Culture™ (SOPS®)
Prepared by
Westat
1600 Research Blvd.
Rockville, MD 20850
under contract number HHSA 2…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
June 02, 2025 - SAY:
The “Identify Defects Through Sensemaking” module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit will help you identify recurring defects in your system and apply CUSP and Sensemaking tools to help reduce the risk of future harm to your patients.
Slide 1
SAY:
Some of the tools that will help…
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www.ahrq.gov/funding/training-grants/pcor/pcortf-di.html
January 01, 2016 - AHRQ Projects Funded by the Patient-Centered Outcomes Research Trust Fund
Dissemination and Implementation
The Agency for Healthcare Research and Quality's (AHRQ) Patient-Centered Outcomes Research Trust Fund projects for training and career development and dissemination and implementation
AHRQ uses some of…
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www.ahrq.gov/news/events/nac/2021-03-nac/nacmtg031821-minutes.html
July 01, 2021 - Meeting Minutes, March 2021
Virtual Meeting
Minutes from the March 18, 2021, virtual meeting of the Agency for Healthcare Research and Quality's National Advisory Council.
Contents
Summary
Call to Order and Approval of November 10, 2020, Meeting Summary
Recent AHRQ Accomplishments
Update on AHRQ Bud…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Stock_72.pdf
January 01, 2007 - The PeaceHealth Ambulatory Medication Safety Culture Survey
The PeaceHealth Ambulatory Medication
Safety Culture Survey
Ronald Stock, MD; Eldon R. Mahoney, PhD
Abstract
Objective: The objective of this project was to construct a measure of medication safety culture
in ambulatory settings. Methods: A 16-it…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/small-conf_impact_final_report.docx
January 01, 2011 - IMPaCT Multi-State Conference
February 21-22, 2013
Final Progress Report
Award Information
Principle Investigator: James W. Mold, MD, MPH
Grant Recipient: University of Oklahoma Health Sciences Center
Team Members: Daren DeWalt, MD (North Carolina), Arthur Kaufman, MD (New Mexico), Robert Gabbay, MD (Pennsylvania), …
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psnet.ahrq.gov/node/49566/psn-pdf
July 01, 2008 - What Was in Those Platelets?
July 1, 2008
Yomtovian R. What Was in Those Platelets? . PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/what-was-those-platelets
The Case
A 47-year-old woman was admitted to the hospital for complex spinal surgery. The surgery went well
without complications, and postoperativel…
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep
January 1, 2019
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
Case Objectives
List the patient safety events that are unique to in…
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psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
October 01, 2016 - In Conversation With… Richard Platt, MD, MSc
October 1, 2016
Also Read an Essay
Citation Text:
In Conversation With… Richard Platt, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely-intensive-care
October 30, 2024 - The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department
Save
Save to your library
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psnet.ahrq.gov/web-mm/what-was-those-platelets
August 28, 2024 - What Was in Those Platelets?
Citation Text:
Yomtovian R. What Was in Those Platelets? . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
February 01, 2006 - Removing Insult from Injury—Disclosing Adverse Events
Albert W. Wu, MD, MPH | February 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Wu AW. Removing Insult from Injury—Disclosing Adverse Events. PSNet [internet]. Rock…
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - SPOTLIGHT CASE
Spotlight: Mistaken Attribution, Diagnostic Misstep
Citation Text:
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citat…
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digital.ahrq.gov/sites/default/files/docs/publication/r21hs018214-olson-final-report-2012.pdf
January 01, 2012 - Healthy Teens TXT ME: Information Technology to Change Teen Health Risk Behaviors - Final Report
1
TXT ME; IT to change teen health risk behaviors
Ardis L. Olson MD, PI
Research Team Members: Christina Divoll BA, Cecelia Gaffney Med,
Rachel Sarnoff BA, Heather Binnie BA
Ge…
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psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
March 30, 2020 - In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD
March 30, 2020
Also Read the Essay
Citation Text:
In Conversation With.. Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD. PSNet [internet]. 2020.In Conversation With... Ann Gaffey, RN, MS…
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psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - SPOTLIGHT CASE
Total Parenteral Nutrition, Multifarious Errors
Citation Text:
Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
…
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psnet.ahrq.gov/perspective/conversation-maureen-bisognano
February 26, 2025 - In Conversation With… Maureen Bisognano
June 1, 2015
Citation Text:
In Conversation With… Maureen Bisognano. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
…
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digital.ahrq.gov/sites/default/files/docs/behavior-change-slides-07172025.pdf
July 17, 2025 - Empowering Patients To Change Behavior Using Digital Healthcare Tools
Empowering Patients To Change Behavior Using
Digital Healthcare Tools
Presented by:
May May Leung, Ph.D., R.D.N.
David Dorr, M.D., M.S.
Moderated by:
Kevin Chaney, M.G.S.
Agency for Healthcare Research and Qu…