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psnet.ahrq.gov/taxonomy/term/3460
November 10, 2025 - Swiss Cheese Model
Reason developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard. In the model, each slice of cheese represents a safety barrier or precaution relevant to a particular …
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/needs-assessment
January 01, 2023 - Needs Assessment
Examples
Walker J, Bieber E, Richards F, et al. Appendix 2: physician reporting and digital storage system needs assessment - endoscopy suite. In: Walker J, Bieber E, Richards F, editors. Implementing an electronic health record system. London: Springer; 2005. p. 183-91.
Des…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/decision-tree
January 01, 2023 - Decision Tree
Also Known As
Decision Process Flowchart
Logic Diagram
Description
Decision trees are tools that can be utilized to navigate several courses of action to arrive on one choice. Their structure allows one to evaluate multiple options and explore what the potential outcomes ar…
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psnet.ahrq.gov/issue/holding-out-apology
January 19, 2024 - Commentary
Holding out for an apology.
Citation Text:
Holding out for an apology. BMJ. 2018;363:k3033. doi:10.1136/bmj.k3033.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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…
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www.ahrq.gov/sites/default/files/2024-07/cox-carayon-report.pdf
January 01, 2024 - Thus, engaging families in FCR provides a regularly occurring
interaction for families to influence the
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/-6kN7TPcfEj2owG4GTN2jA
June 01, 2012 - consecutive negative HPV results
within 10 years before cessation of screening, with the
most recent test occurring
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www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/syphilis-infection-pregnant-persons
November 19, 2024 - Share to Facebook
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Print
in progress
Draft Recommendation Statement
Syphilis Infection During Pregnancy: Screening
November 19, 2024
Recommendations made by the USPSTF are independent of the U.S. …
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www.ahrq.gov/research/shuttered/toolkitchecklist/surgetkit2.html
July 01, 2018 - Facilities
Public Health Emergency Preparedness
1. Preplanning
Description: Certain equipment, services, or staffing required for surge use of the shuttered hospital will necessitate advance arrangements, including identification of providers, contracts, specifications, and protocols.
Timeframe: As soon…
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www.ahrq.gov/sites/default/files/2024-01/gandhi-report.pdf
January 01, 2024 - Final Progress Report: Using Barcode Technology to Improve Medication Safety
FINAL REPORT: April 16, 2007
Using Barcode Technology to Improve Medication Safety
Principal Investigator: Tejal Gandhi, tgandhi@partners.org
Brigham and Women’s Hospital
Tejal Gandhi MD, MPH, Principle Investigator
Eric Poon, MD, MPH, …
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www.ahrq.gov/sites/default/files/2024-11/blumenthal-report.pdf
January 01, 2024 - Final Progress Report: Validation of an Innovative Approach to Error Reduction
Final Progress Report
Validation of an Innovative Approach To Error Reduction
Principal Investigator: David Blumenthal, MD, MPP
Team Members:
Carlos A. Camargo, Jr., MD, DrPH (Massachusetts General Hospital)
Paul D. Cleary, PhD (Yale…
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hcup-us.ahrq.gov/reports/statbriefs/sb164.pdf
October 01, 2013 - Characteristics of Adverse Drug Events Originating During the Hospital Stay, 2011
1
October 2013
Characteristics of Adverse Drug Events
Originating During the Hospital Stay, 2011
Audrey J. Weiss, Ph.D. and Anne Elixhauser, Ph.D.
Introduction
An adverse drug event (ADE) involves patient in…
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/abdominal-aortic-aneurysm-screening-february-2005
February 15, 2005 - Share to Facebook
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Print
archived
Final Recommendation Statement
Abdominal Aortic Aneurysm: Screening
February 15, 2005
Recommendations made by the USPSTF are independent of the U.S. government.…
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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - SPOTLIGHT CASE
Falling Through the Crack (in the Bedrails)
Citation Text:
Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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F…
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hcup-us.ahrq.gov/reports/statbriefs/sb81.pdf
April 01, 2010 - Statistical Brief #81: The Costs of End-of_Life Hospitalizations, 2007
From
HEALTHCARE COST AND
UTILIZATION PROJECT
Agency for Healthcare
Research and Quality
STATISTICAL BRIEF #81
Highlights
■ Thirty-two percent of all deaths in
the U.S. in 2007 were inpatient
hospital deaths.
■ T…
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hcup-us.ahrq.gov/reports/statbriefs/sb136.pdf
March 01, 2012 - Statistical Brief #137: Hospital Visits in the U.S. for Firearm-Related Injuries, 2009
1
June 2012
Hospital Visits in the U.S. for Firearm-
Related Injuries, 2009
Alison Evans Cuellar, Ph.D., Elizabeth Stranges, M.S., and
Carol Stocks, R.N., M.H.S.A.
Introduction
Firearm injuries make up …
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hcup-us.ahrq.gov/reports/statbriefs/sb48.pdf
March 01, 2008 - Statistical Brief #48: Violence-Related Stays in U.S. Hospitals, 2005
HEALTHCARE COST AND
UTILIZATION PROJECT Agen
Rese
March 2008
In 200
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hospit
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4.2 pe
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f…
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psnet.ahrq.gov/node/49604/psn-pdf
June 01, 2010 - Tacit Handover, Overt Mishap
June 1, 2010
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
The Case
A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3
years earlier to treat an abdo…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.140_slideshow.ppt
December 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case December 2006
Hidden Heparins: HIT Happens
Source and Credits
This presentation is based on the December 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Patrick F. Fogarty,…
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www.ahrq.gov/teamstepps-program/curriculum/intro/explain.html
July 01, 2023 - Section 2: Explanation and Value of the TeamSTEPPS Curriculum
This section contains explanations and illustrations to help you better understand and appreciate the structure and importance of the TeamSTEPPS curriculum and its key concepts. If you teach this content or want additional insights into how the mate…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/aom-children-guide.docx
September 01, 2022 - The “Sometimes Antibiotics” Diagnoses: Acute Otitis Media in Children – Facilitator Guide
AHRQ Safety Program for Improving Antibiotic Use
1
The “Sometimes Antibiotics” Diagnoses: Acute Otitis Media in Children
Ambulatory Care
Slide Title and Commentary
Slide Number and Slide
The “Sometimes Antibiotics” Diagno…