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  1. 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…
  2. 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…
  3. 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…
  4. Sensemakingnotes (doc file)

    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…
  5. 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…
  6. 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…
  7. 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…
  8. 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), …
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. 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. …
  12. 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 Print Download PDF Share Facebook Twitter Linkedin Copy URL …
  13. 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…
  14. 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…
  15. 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…
  16. 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…
  17. 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…
  18. 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. Copy Citation Format: …
  19. 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. Copy Citation Format: …
  20. 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…