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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Potter.pdf
January 01, 2003 - An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors
39
An Analysis of Nurses’ Cognitive Work:
A New Perspective for Understanding
Medical Errors
Patricia Potter, Laurie Wolf, Stuart Boxerman, Deborah Grayson,
Jennifer Sledge, Clay Dunagan, Bradley Evanoff
Abstract
He…
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www.ahrq.gov/sops/bibliography/index.html?page=5
January 01, 2025 - Assessing patient safety culture in Tunisian operating rooms: A multicenter study.
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www.ahrq.gov/es/sops/bibliography/index.html?page=5
January 01, 2025 - Assessing patient safety culture in Tunisian operating rooms: A multicenter study.
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/guide4.html
October 01, 2017 - Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization
Training Guide
Module Aim
The aim of this module is to support your efforts to implement the new prevention practices at the patient care level.
Module Goals
The goals of the Module 4 training are to have the Implem…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/module4_pu-implementation.docx
June 02, 2025 - Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization
Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization
Module Aim
The aim of this module is to support your efforts to implement the new prevention practices at the patient care level.
Module Goals…
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www.ahrq.gov/research/findings/final-reports/stpra/stpra3.html
April 01, 2018 - In much the same way that Bundles of Care have extrapolated care from the operating room to the bedside
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www.ahrq.gov/ncepcr/tools/workforce-financing/exec-summary.html
July 01, 2019 - Executive Summary
Workforce Configurations to Provide High-Quality, Comprehensive Primary Care
As the U.S. health care system seeks to reconfigure primary care to meet the needs of an aging and more complex population, environmental factors such as the advent of team care and the patient-centered …
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/09-diagnostic-safety-practice-orientation.pptx
November 24, 2020 - Co-producing a Diagnosis
Engaging Patients To Improve Diagnostic Safety
Practice Orientation
AHRQ Publication No. 21-0047-8-EF
August 2021
1
Diagnostic Errors Are a
Big Challenge
Nearly every person will experience a diagnostic error in their lifetime.
Diagnostic error is the leading patient safety challenge…
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hcup-us.ahrq.gov/reports/statbriefs/sb154.pdf
March 01, 2013 - subsequent hospital admission within 30 days
following an original admission (or index stay) with a major operating … room procedure that occurred from
January through November 2010.
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psnet.ahrq.gov/node/49605/psn-pdf
June 01, 2010 - Upon hospital arrival, the patient was rushed to the operating room for
emergency C-section.
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www.ahrq.gov/hai/cusp/toolkit/content-calls/assertion.html
April 01, 2013 - Appropriate Assertion Call (Transcript)
December 14, 2010
Operator: Good day, ladies and gentleman and welcome to the CUSP Content Call. At this time, all participants are in a listen only mode. Later, we will conduct a question-and-answer session, and instructions will follow at that time. If anyone should …
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effectivehealthcare.ahrq.gov/system/files/docs/topic-brief-hospital-length-of-stay.pdf
November 01, 2019 - studies found an increase in daytime operating,
improved patient transit from emergency department to operating … room to
home, and decreased length of stay
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psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy
November 13, 2024 - The patient was taken immediately to the operating room and was found to have diffuse peritonitis secondary
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psnet.ahrq.gov/node/73202/psn-pdf
April 28, 2021 - A Postpartum Woman with an Erroneous SARS-CoV-2
Test
April 28, 2021
Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
The Case
A full-term pregnant patient was admitted in March 2…
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psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - A Postpartum Woman with an Erroneous SARS-CoV-2 Test
Citation Text:
Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
Copy Citation
Forma…
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psnet.ahrq.gov/perspective/ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
August 31, 2020 - Annual Perspective
AHRQ PSNet Annual Perspective: Impact of the COVID-19 Pandemic on Patient Safety
March 30, 2021
View more articles from the same authors.
Citation Text:
Stocking JC, Sandrock C, Fitall E, et al. AHRQ PSNet Annual Perspective: Impact of the…
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psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
December 01, 2010 - analyses and in separate studies.( 10 , 13 , 14 ) As a result, RMF has put in place interventions in the operating … room that address team communication and skills assessment.( 15 ) Armed with the claims data and supporting … A prospective study of patient safety in the operating room. Surgery. 2006;139:159-173.
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hcup-us.ahrq.gov/reports/methods/2010_06.pdf
January 01, 2010 - room
procedure (excluding patients with respiratory disease, circulatory disease, neuromuscular disorders … failure), age less than 18 years
PDI 10 Postoperative sepsis per 1,000 surgery discharges with an operating … room procedure (excluding
patients admitted for infection; neonates; stays under 4 days; and admissions … PSI 11 Postoperative respiratory failure per 1,000 elective surgical discharges with an operating room … PSI 13 Postoperative sepsis per 1,000 elective-surgery discharges with an operating room procedure
(
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www.ahrq.gov/sites/default/files/2025-03/connors-report.pdf
January 01, 2025 - nature of adverse events during
pediatric sedation/anesthesia with propofol for procedures outside the operating … room: a
report from the Pediatric Sedation Research Consortium. … Sedation and analgesia in pediatric patients for procedures
outside the operating room. … Standardizing care and monitoring for anesthesia or
procedural sedation delivered outside the operating … room.
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psnet.ahrq.gov/node/866847/psn-pdf
September 25, 2024 - In Conversation with Carole Stockmeier about Zero Harm:
Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 25, 2024
Stockmeier CA, Mossburg S, Lee M. In Conversation with Carole Stockmeier about Zero Harm: Striving to
Reduce Preventable Harms – Point, Counterpoint, and Are…