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3621. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
      January 01, 2024 - Spotlight Spotlight Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns 1 Source and Credits This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary …

3622. Danger in Disruption | PSNet
      psnet.ahrq.gov/web-mm/danger-disruption
      July 29, 2020 - Danger in Disruption Citation Text: Fontaine DK. Danger in Disruption. 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 Endnote tagged PubMedI…

3623. Final Progress Report: Risk Assessment of Pediatric Emergency Transfers (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/holl-report.pdf
      January 01, 2025 - Final Progress Report: Risk Assessment of Pediatric Emergency Transfers Risk Assessment of Pediatric Emergency Transfers Final Report AHRQ P20 HS17125-01 Project Period: 09.31.07 – 02.28.09 Principal Investigator: Jane L. Holl, MD, MPH Northwestern University Institute for Healthcare Studies Co- Investigators: D…

3624. Using Lean Six Sigma® Tools to Compare INR Measurements from Different Laboratories Within a Community (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Hurley_55.pdf
      March 07, 2008 - Results outside that region were unlikely (low probability of occurring), based on that patient’s historical

3625. The Case for Investing in Patient Safety in Canada. | PSNet
      psnet.ahrq.gov/issue/case-investing-patient-safety-canada
      October 05, 2021 - Book/Report The Case for Investing in Patient Safety in Canada. Citation Text: The Case for Investing in Patient Safety in Canada. RiskAnalytica. Ottawa, ON: Canadian Patient Safety Institute; 2017. Copy Citation Save Save to your library Print Download …

3626. Noise: a distraction, interruption, and safety hazard. | PSNet
      psnet.ahrq.gov/issue/noise-distraction-interruption-and-safety-hazard
      February 01, 2014 - Commentary Noise: a distraction, interruption, and safety hazard. Citation Text: Beyea SC. Noise: a distraction, interruption, and safety hazard. AORN J. 2007;86(2):281-5. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…

3627. Distractions, interruptions, and patient safety. | PSNet
      psnet.ahrq.gov/issue/distractions-interruptions-and-patient-safety
      February 01, 2014 - Commentary Distractions, interruptions, and patient safety. Citation Text: Beyea SC. Distractions, interruptions, and patient safety. AORN J. 2007;86(1):109-12. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

3628. Administering just the diluent or one of two vaccine components leaves patients unprotected. | PSNet
      psnet.ahrq.gov/issue/administering-just-diluent-or-one-two-vaccine-components-leaves-patients-unprotected
      May 07, 2018 - Newspaper/Magazine Article Administering just the diluent or one of two vaccine components leaves patients unprotected. Citation Text: Administering just the diluent or one of two vaccine components leaves patients unprotected. ISMP Medication Safety Alert! Acute care edition. May 22, 20…

3629. Slide 1
      cds.ahrq.gov/sites/default/files/cds/artifact/106/HWI_2017.pptx
      January 01, 2017 - Slide 1 Background Methods Impact of Multiple Clinician Focused Interventions on Childhood Obesity Documentation and Management For more information, please contact: Email: michelj@email.chop.edu Jeremy Michel, MD, MHS1,2, Jeffrey Miller, MAS1, Emil…

3630. Resident And Family Engagement: What is my role as a leader? | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/engage/leader.html
      March 01, 2017 - Resident And Family Engagement: What is my role as a leader? AHRQ Safety Program for Long-Term Care: HAIs/CAUTI What is resident and family engagement? Resident and family engagement is one component of person-centered care, a philosophy that recognizes residents as individuals and as partners…

3631. California Hospital Reduced Infections, Improved Diabetes Care with AHRQ Safety Program | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsroom/case-studies/201807.html
      November 01, 2018 - California Hospital Reduced Infections, Improved Diabetes Care with AHRQ Safety Program Search All Impact Case Studies November 2018 Tri-City Medical Center, a 388-bed hospital in Oceanside, California, reduced central line-associated bloodstream infections (CLABSIs) by 33 percent and improved the on-time d…

3632. CAHPS (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/instructions/suppl_pcmh_items_cg-cahps-child-survey_2358-2a.docx
      June 02, 2025 - CAHPS CAHPS® Clinician & Group Survey 3.0 Supplemental Items: Patient-Centered Medical Home Population Version: Child Supplemental Patient-Centered Medical Home Items for the CAHPS® Clinician & Group Survey 3.0 Population Version: Child Language: English Read about the Patient-Centered Medical Home Item Set. …

3633. Teaching Pre-Implementation Measurement | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/implement/pre-measure.html
      May 01, 2023 - Teaching Pre-Implementation Measurement Present Slide 12, “Measurement.” Use this slide to introduce the topic of measurement and note that it is key to all organizational improvement initiatives. In discussing Slide 13, “Define a Measurable Goal or Problem You Plan To Address,” it’s important to stress t…

3634. Exhibit 3.2. Grand Hospital Center | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-2.html
      November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 3.2. Grand Hospital Center Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Healthcare Case 2. Central Hospital…

3635. Reviewing the Team's Performance: Debrief | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/team/tools/debrief.html
      December 01, 2023 - Reviewing the Team's Performance: Debrief Research has shown that teams that effectively debrief their own performance can improve their teamwork in real time. 1 , 2 , 3 , 4   Although it is often difficult to find time for such reviews in healthcare, TeamSTEPPS advocates for after-action reviews; TeamSTEPPS ch…

3636. Location Release Form for Video Shoots (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/publications/pubcomguide/Location-Release-fillable-form.pdf
      April 01, 2024 - Location Release Form for Video Shoots Location Release Form for Video Shoots Instructions This Location Release Form must be completed by the location’s Administrator to verify permission to conduct video recording(s) at a particular location. It does not apply to recordings on government property, which may re…

3637. Guides and Resources for Operationalizing Your MRSA and SSI Prevention Program | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mrsa-prevention/surgery/operationalizing-prevention-program.html
      September 01, 2025 - MRSA Prevention Toolkit: Targeting SSI Guides and Resources for Operationalizing Your MRSA and SSI Prevention Program Previous Page   Table of Contents MRSA Prevention Toolkit: Targeting SSI The Four Key Strategies of MRSA Prevention: Targeting SSI MRSA and SSI Prevention Phases Importance of …

3638. Universal ICU Decolonization Protocol Overview | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-overvw.html
      September 01, 2013 - Universal ICU Decolonization: An Enhanced Protocol Universal ICU Decolonization Protocol Overview Previous Page Next Page Table of Contents Universal ICU Decolonization: An Enhanced Protocol Introduction and Welcome Universal ICU Decolonization Protocol Overview Scientific Rationale Referenc…

3639. Tool: Check-Back (or Repeat-Back) | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/communication/tools/checkback.html
      July 01, 2023 - Tool: Check-Back (or Repeat-Back) A check-back, which is sometimes called a repeat-back, is a closed-loop communication strategy used to verify and validate exchanged information. When a team member calls out information, they typically anticipate a check-back in response to verify that the information was rece…

3640. What Can Leaders Achieve by Prioritizing Diagnostic Safety? | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-4.html
      June 01, 2021 - Leadership To Improve Diagnosis: A Call to Action What Can Leaders Achieve by Prioritizing Diagnostic Safety? Previous Page Next Page Table of Contents Leadership To Improve Diagnosis: A Call to Action Diagnostic Safety as a Challenge for Healthcare Leadership Why Are Leaders Essential to Diagno…