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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/mod03-gap-analysis-guide.pdf
April 01, 2016 - Purpose: To evaluate the extent to which current processes align with the Communication and Optimal Resolution
(CANDOR) process and includes;
■ Identifying the existing process
■ Identifying the existing outcome(s)
■ Identifying the desired outcome(s)
■ Identifying and documenting the gap(s)
Who should use t…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_sr-execs_facnotes.docx
December 01, 2017 - Facilitator Guide: Engage Senior Executives in Surgical Site Infection Prevention Work
Engaging Senior Executives – Facilitator Notes
Slide Title and Commentary
Slide Number and Slide
Title Slide
Engaging Senior Executives
SAY:
In this module we will discuss the importance of senior engagement on your safety pr…
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www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/learn-from-defects.html
December 01, 2017 - Learn From Defects Tool—Perioperative Setting
AHRQ Safety Program for Surgery
What is a defect? A defect is any event or situation that you don’t want to repeat. This could include an incident that caused patient harm or put patients at risk for harm, such as a patient fall.
Problem statement: …
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www.ahrq.gov/hai/tools/surgery/modules/on-boarding/sr-exec-slides.html
December 01, 2017 - Engaging Senior Executives: Facilitator Notes
AHRQ Safety Program for Surgery
Slide 1: Engaging Senior Executives
Say:
In this module we will discuss the importance of senior engagement on your safety program team.
Slide 2: Why Do We Need an Executive?
Say:
Sometimes getting executives involved …
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psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - SPOTLIGHT CASE
Patient Safety Events Involving Opioid Dose Stacking
Citation Text:
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/obtain-training-and-support/pharmacotherapy-training
January 01, 2023 - An official website of the Department of Health & Human Services
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psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
August 31, 2022 - SPOTLIGHT CASE
Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.
Citation Text:
Keenan KJ, Nishijima DK. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - SPOTLIGHT CASE
Do Not Disturb!
Citation Text:
Duffy DF, Cassel C. Do Not Disturb!. 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…
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psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
June 14, 2023 - Management of Cardiac Arrest in Unconventional Locations.
Citation Text:
Agrawal G, Molla M. Management of Cardiac Arrest in Unconventional Locations.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Format: …
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psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
June 01, 2003 - SPOTLIGHT CASE
Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care
Citation Text:
Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of H…
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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.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
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psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
May 19, 2021 - SPOTLIGHT CASE
Postdischarge Follow-Up Phone Call
Citation Text:
Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Schol…
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psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
June 02, 2021 - SPOTLIGHT CASE
Chest Pain in a Rural Hospital
Citation Text:
MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
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psnet.ahrq.gov/node/33752/psn-pdf
August 01, 2013 - In Conversation With… J. Bryan Sexton, PhD, MA
August 1, 2013
In Conversation With… J. Bryan Sexton, PhD, MA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
Editor's note: J. Bryan Sexton, PhD, is associate professor and director of the Patient Safety Center for
the D…
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digital.ahrq.gov/sites/default/files/docs/publication/r21hs022166-beebe-final-report-2016.pdf
January 01, 2016 - The Long Term Effectiveness of Telephone Intervention Problem Solving (TIPS) - Final Report
The long term effectiveness of Telephone Intervention Problem Solving (TIPS).
PI Lora Humphrey Beebe, PhD, PMHNP-BC
Team members:
Kathleen D Smith, PhD, interventionist;
Abbas Tavakoli, PhD…
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - SPOTLIGHT CASE
The Perils of Cross Coverage
Citation Text:
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
February 26, 2025 - In Conversation With… Tejal K. Gandhi, MD, MPH
April 1, 2014
Citation Text:
In Conversation With… Tejal K. Gandhi, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
May 26, 2021 - “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records
Citation Text:
MacDonald S. “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
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hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp
September 01, 2025 - Clinical Classifications Software (CCS) for ICD-9-CM
An official website of the Department of Health & Human Services
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digital.ahrq.gov/computerized-provider-order-entry-inpatient
January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…