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  1. Final Progress Report: Using Team Simulation to Improve Error Disclosure to Patients and Safety Culture (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/gallagher2-report.pdf
    January 01, 2024 - first apology, often a considerable period of time had elapsed in the disclosure without an apology occurring … Other teams offered an apology for the event occurring without linking it to their actions (see #3 and

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49591/psn-pdf
    October 01, 2009 - Difficult Encounters: A CMO and CNO Respond October 1, 2009 Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond Case Objectives Appreciate the risk of disruptive behavior and understand institutional respons…

  3. Appendix C. Site Visit Protocol | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/final-reports/stpra/stpraapc.html
    April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers Appendix C. Site Visit Protocol Previous Page Next Page Table of Contents Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers Executive Summary Chapter 1. Introduction Chapter 2. S…

  4. TeamSTEPPS® Diagnosis Improvement: Module 4 Leadership - Facilitator’s Notes (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module4-presenters-notes.pdf
    January 05, 2022 - TeamSTEPPS® Diagnosis Improvement: Module 4 Leadership - Facilitator’s Notes Slide 1 TeamSTEPPS® for Diagnosis Improvement                                                                                                                                                                                          …

  5. CAUTI Event Reporting Tool (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-event-reporting_revised.docx
    April 01, 2022 - CAUTI Event Reporting Tool CLABSI Event Report Tool: Data for Event Analysis This event report template is designed to be used as a guide through the initial investigation for a defects analysis where the primary goal is to learn what happened and factors that may have contributed to the central line-associated blo…

  6. Tool: SSA (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/head-bed-elevation-litreview.docx
    January 01, 2017 - Tool: SSA Summary The elevation of the head of bed (HOB) to a semirecumbent position (at least 30 degrees) is associated with a decreased incidence of aspiration and ventilator-associated pneumonia (VAP). The intervention is supported unanimously by all four leading guidelines, and newer publications in the field acc…

  7. AHRQ Safety Program for Perinatal Care: Establishing a Program of In Situ Simulations (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_facguide.pdf
    May 01, 2017 - AHRQ Safety Program for Perinatal Care: Establishing a Program of In Situ Simulations AHRQ Safety Program for Perinatal Care Establishing a Program of In Situ Simulations AHRQ Publication No. 17-0003-22-EF May 2017 SAY: Establishing a Program of In Situ Simulations is a pillar of the AHRQ Safety Program for…

  8. Section 8: The Care Management Evidence Base (continued) | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm8a.html
    October 01, 2014 - Designing and Implementing Medicaid Disease and Care Management Programs Section 8: The Care Management Evidence Base (continued) Previous Page Next Page Table of Contents Designing and Implementing Medicaid Disease and Care Management Programs Introduction Section 1: Planning a Care Management …

  9. Final Progress Report: Videotaping communication between physicians and nurses: A methods study (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/manojlovich-report.pdf
    January 01, 2024 - Final Progress Report: Videotaping communication between physicians and nurses: A methods study TITLE PAGE Title of Project: Videotaping communication between physicians and nurses: A methods study Principal Investigator and Team Members: Milisa Manojlovich (PI), Molly Harrod, Timothy Hofer, Sarah Krein (co-inves…

  10. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
    January 01, 2022 - Spotlight Spotlight Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong Source and Credits • This presentation is based on the October 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861760/psn-pdf
    January 31, 2024 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery January 31, 2024 Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49611/psn-pdf
    October 01, 2010 - The Deadly Duo October 1, 2010 Maldonado JR. The Deadly Duo. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/deadly-duo The Case A 29-year-old man with a history of depression and possible psychosis was found unconscious and unresponsive at home and was brought to the emergency department. He was tachycardi…

  13. Statistical Brief #127: 30-Day Readmissions following Hospitalizations for Chronic vs. Acute Conditions, 2008 (pdf file)

    hcup-us.ahrq.gov/reports/statbriefs/sb127.pdf
    February 01, 2012 - Statistical Brief #127: 30-Day Readmissions following Hospitalizations for Chronic vs. Acute Conditions, 2008 1 February 2012 30-Day Readmissions following Hospitalizations for Chronic vs. Acute Conditions, 2008 Jennifer Podulka, M.P.Aff., Marguerite Barrett, M.S., H. Joanna Jiang, Ph.D., and…

  14. Duplicate Therapies in Retail Pharmacy | PSNet

    psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
    August 05, 2022 - Duplicate Therapies in Retail Pharmacy Citation Text: Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX E…

  15. All in the History | PSNet

    psnet.ahrq.gov/web-mm/all-history
    February 28, 2011 - SPOTLIGHT CASE All in the History Citation Text: Fee C. All in the History. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…

  16. Parisetal Hfes2008 (pdf file)

    digital.ahrq.gov/sites/default/files/docs/publication/Parisetal_HFES2008.pdf
    January 01, 2008 - Safety of the Antibiotic Medication Use Process in the Intensive Care Unit Bonnie Paris�, Pascale Carayon�, Tosha Wetterneck� Department of Industrial & Systems Engineering, University of Wisconsin-Madison�; University of Wisconsin School of Medicine and Public Health�; Center for Quality & Productivity Improvem…

  17. Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle | PSNet

    psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
    July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 29, 2024 View more articles from the same authors. Inno…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49801/psn-pdf
    August 01, 2017 - Despite Clues, Failed to Rescue August 1, 2017 Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue Case Objectives Define failure to rescue. Identify the main contributors to failure-to-rescue events. Appreciate the ongoing areas of scien…

  19. Hemorrhage-Postpartum Executive (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/hemorrhage-postpartum_executive.pdf
    April 01, 2015 - PPH is often classified as primary/immediate/early, occurring within 24 hours of birth, or secondary … /delayed/ late, occurring from more than 24 hours postbirth to up to 12 weeks postpartum.

  20. Improving the Value of Patient Safety Reporting Systems (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
    June 12, 2008 - Improving the Value of Patient Safety Reporting Systems Improving the Value of Patient Safety Reporting Systems Peter J. Pronovost, MD, PhD; Laura L. Morlock, PhD; J. Bryan Sexton, PhD; Marlene R. Miller, MD, MSc; Christine G. Holzmueller, BLA; David A. Thompson, DNSc, MS; Lisa H. Lubomski, PhD; Albert W. Wu, M…
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