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psnet.ahrq.gov/node/41668/psn-pdf
December 21, 2014 - A surgical simulation curriculum for senior medical
students based on TeamSTEPPS.
December 21, 2014
Meier AH, Boehler ML, McDowell CM, et al. A surgical simulation curriculum for senior medical students
based on TeamSTEPPS. Arch Surg. 2012;147(8):761-6. doi:10.1001/archsurg.2012.1340.
https://psnet.ahrq.gov/issue/…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-f.docx
June 02, 2025 - PROMPTLY REMOVE
AHRQ Safety Program for Reducing CAUTI in Hospitals
Appendix F. Urinary Catheter Decision-Making Algorithm
Is there a urinary catheter in place?
Does the patient meet criteria for catheter placement?
Avoid catheter placement.
Accepted Urinary Catheter
Placement Indications
1. Acute urinary retentio…
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psnet.ahrq.gov/node/855439/psn-pdf
December 07, 2023 - Bringing a ‘Systemness’ Focus to Quality, Safety, and
Patient Experience.
November 15, 2023
American Hospital Association. December 7, 2023.
https://psnet.ahrq.gov/issue/bringing-systemness-focus-quality-safety-and-patient-experience
Health care organizations require a systems approach to address patient safety ch…
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psnet.ahrq.gov/node/42345/psn-pdf
June 12, 2013 - With money at risk, hospitals push staff to wash hands.
June 12, 2013
Armellino D, Hussain E, Schilling ME, et al. Using High-Technology to Enforce Low-Technology Safety
Measures: The Use of Third-party Remote Video Auditing and Real-time Feedback in Healthcare. Clinical
Infectious Diseases. 2011;54(1). doi:10.1093…
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psnet.ahrq.gov/node/47371/psn-pdf
September 26, 2018 - When I say…diagnostic error.
September 26, 2018
Hautz WE. When I say… diagnostic error. Med Educ. 2018. doi:10.1111/medu.13602.
https://psnet.ahrq.gov/issue/when-i-saydiagnostic-error
Inconsistent terminology use in research, education, and measurement strategy development hinders
progress and understanding in eme…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-230-section-6-table-6-7.pdf
June 02, 2025 - CHIPRA 230: Section 6, Tables 6 and 7
Table 6: Agreement and Kappa Statistics for Inter-Rater Reliability
Variable Description
Records
Reviewed
For IRR (N)
N Agreed
(%)
Kappa
Statistic
Documentation of BMI percentile 59 58 (98) 0.982
Documentation of weight classification 59 55 (93) 0.924
…
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psnet.ahrq.gov/node/45134/psn-pdf
August 10, 2016 - Patient Safety: Exploring Quality of Care in the US.
August 10, 2016
ProPublica, Inc. New York, NY. 2012-2016.
https://psnet.ahrq.gov/issue/patient-safety-exploring-quality-care-us
This website provides resources exploring patient safety challenges from various perspectives, including
feature length articles and m…
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psnet.ahrq.gov/node/42516/psn-pdf
February 04, 2016 - "Excuse me": teaching interns to speak up.
February 4, 2016
O'Connor P, Byrne D, O'Dea A, et al. "Excuse me:" teaching interns to speak up. Jt Comm J Qual Patient
Saf. 2013;39(9):426-431.
https://psnet.ahrq.gov/issue/excuse-me-teaching-interns-speak
Previous research has shown that junior physicians may be unwilli…
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psnet.ahrq.gov/node/37216/psn-pdf
July 28, 2010 - Discharge rounds in the 80-hour workweek: importance of
the trauma nurse practitioner.
July 28, 2010
Haan JM, Dutton RP, Willis M, et al. Discharge rounds in the 80-hour workweek: importance of the trauma
nurse practitioner. J Trauma. 2007;63(2):339-43.
https://psnet.ahrq.gov/issue/discharge-rounds-80-hour-workwee…
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psnet.ahrq.gov/node/40865/psn-pdf
September 12, 2016 - A review of current and emerging approaches to address
failure-to-rescue.
September 12, 2016
Taenzer AH, Pyke JB, McGrath SP. A review of current and emerging approaches to address failure-to-
rescue. Anesthesiology. 2011;115(2):421-31. doi:10.1097/ALN.0b013e318219d633.
https://psnet.ahrq.gov/issue/review-current-…
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psnet.ahrq.gov/node/863000/psn-pdf
February 21, 2024 - Why engineers are working to build better pulse
oximeters.
February 21, 2024
Willyard C. MIT Technology Review. February 9, 2024.
https://psnet.ahrq.gov/issue/why-engineers-are-working-build-better-pulse-oximeters
Engineers play an important role in the development and manufacturing of medical devices with an eye
…
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psnet.ahrq.gov/node/43185/psn-pdf
May 14, 2014 - Preventing health care–associated harm in children.
May 14, 2014
Walsh KE, Bundy DG, Landrigan CP. Preventing health care-associated harm in children. JAMA.
2014;311(17):1731-2. doi:10.1001/jama.2014.2038.
https://psnet.ahrq.gov/issue/preventing-health-care-associated-harm-children
This commentary describes why de…
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psnet.ahrq.gov/training-catalog/building-safety-culture-and-strengthening-hospital-safety-systems
July 07, 2025 - Building Safety Culture and Strengthening Hospital Safety Systems
Save
Save to your library
Print
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Organization:
Organization
Hospital Quality Institute
E…
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psnet.ahrq.gov/node/35443/psn-pdf
September 18, 2009 - The nuclear power industry as an alternative analogy for
safety in anaesthesia and a novel approach for the
conceptualisation of safety goals.
September 18, 2009
Webster CS. The nuclear power industry as an alternative analogy for safety in anaesthesia and a novel
approach for the conceptualisation of safety goals…
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psnet.ahrq.gov/node/38008/psn-pdf
August 27, 2008 - The Team Climate Inventory: application in hospital teams
and methodological considerations.
August 27, 2008
Ouwens M, Hulscher M, Akkermans R, et al. The Team Climate Inventory: application in hospital teams
and methodological considerations. Qual Saf Health Care. 2008;17(4):275-80.
doi:10.1136/qshc.2006.021543.
…
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psnet.ahrq.gov/node/41537/psn-pdf
December 30, 2014 - Deaths due to medical error: jumbo jets or just small
propeller planes?
December 30, 2014
Shojania KG. Deaths due to medical error: jumbo jets or just small propeller planes? BMJ Qual Saf.
2012;21(9). doi:10.1136/bmjqs-2012-001368.
https://psnet.ahrq.gov/issue/deaths-due-medical-error-jumbo-jets-or-just-small-prop…
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www.ahrq.gov/antibiotic-use/long-term-care/best-practices/cellulitis.html
May 01, 2022 - Assessment and Management of the Resident With a Suspected Skin or Soft Tissue Infection
After viewing or presenting this presentation, viewers will be able to—
Distinguish infectious cellulitis versus cellulitis mimics.
Discuss the diagnostic approach and empiric management of skin and soft tissue inf…
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psnet.ahrq.gov/node/42284/psn-pdf
May 22, 2013 - Current approaches to punitive action for medication
errors by boards of pharmacy.
May 22, 2013
Holdsworth M, Wittstrom K, Yeitrakis T. Current approaches to punitive action for medication errors by
boards of pharmacy. Ann Pharmacother. 2013;47(4):475-81. doi:10.1345/aph.1R668.
https://psnet.ahrq.gov/issue/current…
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psnet.ahrq.gov/node/43434/psn-pdf
August 06, 2014 - Maryland hospitals aren't reporting all errors and
complications, experts say.
August 6, 2014
Cohn M.
https://psnet.ahrq.gov/issue/maryland-hospitals-arent-reporting-all-errors-and-complications-experts-say
This news article reports weaknesses in a Maryland reporting program, including poor understanding about
wh…
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psnet.ahrq.gov/node/850935/psn-pdf
June 21, 2023 - Non–operating room anesthesia challenges.
June 21, 2023
Smith MJ. Anesthesiology News. June 6, 2023.
https://psnet.ahrq.gov/issue/non-operating-room-anesthesia-challenges
The use of office-based anesthesia presents both care improvements and risks for patients and clinical
teams. This article summarizes frontline …