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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Wideman.pdf
April 20, 2004 - As much as 30 minutes could elapse between the provider’s order
entry and the appearance of either type … patient safety manager in February 2004 noted the tool had been
used several times in the span of 20 minutes
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www.ahrq.gov/patient-safety/reports/engage/faq.html
April 01, 2018 - Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families
Frequently Asked Questions
Implementation
Be Prepared to Be Engaged
Create a Safe Medicine List Together
Teach-Back
Warm Handoff Plus
Implementation
1. How do I get leadership buy-in?
Leaders play an imp…
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR
Citation Text:
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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…
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psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - Is It Safe to Be Direct?
Citation Text:
Kulkarni NS, Williams M. Is It Safe to Be Direct?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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integrationacademy.ahrq.gov/sites/default/files/2025-04/AHRQ_Integration_Academy_Overview-508.pdf
January 01, 2025 - The Academy for Integrating Behavioral Health and Primary Care
The Academy for Integrating Behavioral
Health and Primary Care
https://integrationacademy.ahrq.gov/
https://integrationacademy.ahrq.gov/
What is integrated behavioral health?
• A practice team of primary care and
behavioral health clinicians workin…
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psnet.ahrq.gov/node/33813/psn-pdf
August 01, 2016 - Safety In Dentistry
August 1, 2016
Ramoni R, Walji MF, Kalenderian E. Safety In Dentistry. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/safety-dentistry
Perspective
In a famous scene from the 1976 film, Marathon Man, Laurence Olivier, playing dentist Dr. Christian Szell
tortures Babe Levy (played by…
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psnet.ahrq.gov/node/49394/psn-pdf
April 01, 2003 - Premature or Overdue?
April 1, 2003
Thomas J, Hannah M. Premature or Overdue? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/premature-or-overdue
The Case
A 32-year-old woman, gravida 3, para 1, presented for prenatal care at 24 weeks. Her past medical history
was unremarkable, and results of her prenatal …
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psnet.ahrq.gov/node/853772/psn-pdf
September 27, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not
Interchangeable
September 27, 2023
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
The Case
A fourteen-ye…
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psnet.ahrq.gov/node/49629/psn-pdf
June 01, 2011 - Say It Again
June 1, 2011
Henriksen K, Hall KK. Say It Again. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/say-it-again
The Case
A 72-year-old man was admitted to the hospital with community-acquired pneumonia and hyponatremia.
During his third hospital night, the on-call physician was contacted by the c…
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psnet.ahrq.gov/node/33745/psn-pdf
February 01, 2013 - Patient Engagement and Patient Safety
February 1, 2013
Weingart SN. Patient Engagement and Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
Perspective
Patient engagement has arrived at the station. A Google search of this phrase identified 335,000 hi…
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www.ahrq.gov/teamstepps-program/curriculum/communication/tools/index.html
July 01, 2023 - Section 2: Explanation of Key Concepts and Tools
This section contains explanations and illustrations to help you better understand and appreciate the importance of TeamSTEPPS communication concepts and tools. If you teach this content or want additional insights into how the material can be more fully learned,…
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www.ahrq.gov/hai/tools/mvp/modules/technical/daily-care-processes-slides.html
January 01, 2017 - Measure Descriptions for Daily Care Processes: Slide Presentation
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients
Measure Descriptions for Daily Care Processes
Slide 2: Learning Objectives
After this session, you will be abl…
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integrationacademy.ahrq.gov/sites/default/files/2025-05/AHRQ-Integration-Academy-Overview.pdf
January 01, 2025 - The Academy for Integrating Behavioral Health and Primary Care
The Academy for Integrating Behavioral
Health and Primary Care
https://integrationacademy.ahrq.gov/
https://integrationacademy.ahrq.gov/
What is integrated behavioral health?
• A practice team of primary care and
behavioral health clinicians workin…
-
www.ahrq.gov/sites/default/files/2024-10/li-chang-report.pdf
January 01, 2024 - Final Progress Report: Systematic Evaluation of Operating Room Scheduling Across the Perioperative Process
Systematic Evaluation of Operating Room Scheduling Across the Perioperative Process
Principal Investigator: Wei Li, PhD, PE University of Kentucky
Co-Investigators: Phillip K. Chang, MD UK Healthcare
Team Membe…
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psnet.ahrq.gov/web-mm/patient-mix
December 01, 2007 - Patient Mix-Up
Citation Text:
Shojania KG. Patient Mix-Up. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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psnet.ahrq.gov/web-mm/toxic-tachycardia
March 01, 2005 - Toxic Tachycardia
Citation Text:
Wartofsky L. Toxic Tachycardia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
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www.ahrq.gov/hai/cauti-tools/facil-guide/preventing-cauti-icu-setting-module1-speaker-notes.html
February 01, 2023 - Module 1: Overview - Facilitator's Notes
Preventing CAUTI in the ICU Setting
Slide 1. Preventing CAUTI in the ICU Setting
Say:
"Preventing CAUTI in the ICU Setting" is a four-module program designed for intensive care unit, or ICU, nurses to gain a sense of confidence and demonstrate competence in cathe…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-module_1-speaker-notes.docx
September 01, 2015 - AHRQ Safety Program for Reducing CAUTI in Hospitals
Preventing CAUTI in the ICU Setting
Module 1: Overview
SAY:
“Preventing CAUTI in the ICU Setting” is a four-module program designed for intensive care unit, or ICU, nurses to gain a sense of confidence and demonstrate competence in catheter-associated urinary tra…
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psnet.ahrq.gov/web-mm/weak-response
February 24, 2011 - A "Weak" Response
Citation Text:
Reisman AB. A "Weak" Response. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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…
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psnet.ahrq.gov/node/865570/psn-pdf
April 10, 2024 - Risk Mitigation Using the Anesthesia Risk Alert Program:
Applying a Proactive Approach With Data Review &
Collaborating With a Second Practitioner
April 10, 2024
https://psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-
approach-data
Summary
North American Partners…