-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Learning From Defects: Applying the “Swiss cheese model” of System Failure
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
Slide Title and Commentary
Slide Number and Slide
Learning From Defects: Applying the “Swiss C…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pressureinjury-msmt_slides.pptx
June 02, 2025 - How To Measure Pressure Injury Rates and Prevention Practices
How To Measure
Pressure Injury Rates
and Prevention Practices
ADD Hospital Name Here
Module 5
1
Basic Quality Improvement Principle
If you can’t measure it, you can’t improve it.
2
2
Quality Improvement Principle
Pressure injury rates and preven…
-
www.ahrq.gov/hai/cusp/toolkit/content-calls/org-embrace-slides/slides.html
June 01, 2013 - Organizational Embrace of CUSP to Improve Patient Safety (Slide Presentation)
On the CUSP: Stop BSI
This PowerPoint slide presentation was shown on March 20, 2012.
Contents
Slide 1. The Organizational Embrace of CUSP to Improve Patient Safety
Slide 2. Objectives
Slide 3. Speakers
Slide 4. Holy Cro…
-
www.ahrq.gov/hai/cusp/modules/implement/teamwork.html
December 01, 2012 - Implement Teamwork and Communication
CUSP Toolkit
The Implement Teamwork and Communication module of the CUSP Toolkit will help you to identify barriers to communication.
Contents
Slide 1. Cover Slide
Slide 2. Learning Objectives
Slide 3. Basic Components and Process of Communication 2
Slide 4. Four…
-
psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
October 30, 2024 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates
Save
Save to your library
Print
Download PDF
Share
Facebook
Twitter
Linkedin
Copy URL
February 9, 2021
…
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/measures-spanish.pdf
April 01, 2014 - Spanish Community Pharmacy Survey on Patient Safety Culture Items and Dimensions
Spanish Translation of AHRQ’s Community Pharmacy Survey on Patient Safety Culture
April 2014
This document explains the process that was used to develop a Spanish translation of the Agency for Healthcare
Research and Quality (AHRQ) C…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medmanagement_webinar_slides.pdf
January 01, 2015 - Medication Management
1
Medication Management
AHRQ
Guide to Improving Patient Safety in Primary
Care Settings by Engaging Patients and
Families
Speaker
Kelly Smith, PhD
Scientific Director, Quality & Safety
Co-PI, AHRQ Guide to Improve Patient Safety
in Primary Care Settings by Engaging
Patients …
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-199-section-2-chart-tech-specs.pdf
January 01, 2013 - Section 2, Chart Abstraction Tool and Technical Specifications
Basic Elements
Age upon
Age upon admission
Patient ID Race Ethnicity Gender Payer
Preferred
Language
admission (YEARS)
[e.g. for 12.5 year
(MONTHS) [
e.g. for 12.5
old, years = 12) year old,
months = 6]
1 White Non-Hispanic Female Medicaid E…
-
psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and-intervention-innovation
July 23, 2024 - System Approaches to Social Determinants of Health Screening and Intervention Innovation Summary
Save
Save to your library
Print
Download PDF
Share
Facebook
Twitter
Linkedin
Copy URL
September 23, 2024
View more articles from the same…
-
integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/engaging-and-educating
January 01, 2024 - An official website of the Department of Health & Human Services
Search All AHRQ Sites
Careers
Contact Us
Español
FAQs
Email Updates
The Academy
Integrating Behavioral Health & Primary Care
Expand Navi…
-
digital.ahrq.gov/funding-mechanism/voluntary-consensus-development-standardized-measures
January 01, 2023 - Voluntary Consensus Development of Standardized Measures, Reports, Common Formats, and other Products
Health information technology automation of quality measurement: quality data set and data flow.
Citation
National Quality Forum (NQF). Health Information Technology Automatio…
-
psnet.ahrq.gov/node/44889/psn-pdf
April 13, 2017 - An organizational learning framework for patient safety.
April 13, 2017
Edwards MT. An Organizational Learning Framework for Patient Safety. Am J Med Qual. 2016;32(2):148-
155. doi:10.1177/1062860616632295.
https://psnet.ahrq.gov/issue/organizational-learning-framework-patient-safety
Organizations are encouraged t…
-
digital.ahrq.gov/document-type/logging-tool
January 01, 2023 - Logging Tool
Adverse Drug Events Trigger Tool
Description
The Adverse Drug Events Trigger Tool standardizes the chart review process for ADEs.
Document Source
A Systems Engineering Approach: Improving Medication Safety with Clinician Use of Health IT
…
-
psnet.ahrq.gov/node/867451/psn-pdf
January 21, 2025 - Engineering Safety into Practice through Implementation
of the EHR SAFER Guides.
January 8, 2025
National Action Alliance for Patient and Workforce Safety. Engineering Safety into Practice through
Implementation of the EHR SAFER Guides. January 21, 2025, 12:00 - 1:00 PM (eastern).
https://psnet.ahrq.gov/issue/engi…
-
psnet.ahrq.gov/node/40956/psn-pdf
January 01, 2016 - Michigan Health & Hospital Association Keystone
Obstetrics: a statewide collaborative for perinatal patient
safety in Michigan.
January 31, 2005
Simpson KR, Knox GE, Martin M, et al. Michigan Health & Hospital Association Keystone Obstetrics: A
Statewide Collaborative for Perinatal Patient Safety in Michigan. Jt C…
-
digital.ahrq.gov/ahrq-funded-projects/health-information-technology-supported-process-preventing-and-managing-venous-thromboembolism/citation/application
January 01, 2023 - Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study.
Citation
Carayon P, Hoonakker P, Hundt AS, Salwei M, Wiegmann D, Brown RL, Kleinschmidt P, Novak C, Pulia M, Wang Y, Wirkus E, Patterson B. Application of …
-
digital.ahrq.gov/ahrq-funded-projects/health-information-technology-supported-process-preventing-and-managing-venous-thromboembolism/citation/team
January 01, 2023 - Team adaptation to complex clinical situations: The case of VTE prophylaxis in hospitalized patients.
Citation
Salwei M.E., Carayon, P., Hundt, A.S., Kleinschmidt, P., Hoonakker, P.L.T., Patterson, B.W., Wiegmann, D. (2018). Team adaptation to complex clinical situations: The case of VTE prophylaxis i…
-
psnet.ahrq.gov/node/48081/psn-pdf
January 01, 2021 - Sharing lessons learned to prevent adverse events in
anesthesiology nationwide.
August 21, 2019
Soncrant C, Neily J, Sum-Ping SJT, et al. Sharing Lessons Learned to Prevent Adverse Events in
Anesthesiology Nationwide. J Patient Saf. 2021;17(4):e343-e349. doi:10.1097/PTS.0000000000000616.
https://psnet.ahrq.gov/iss…
-
psnet.ahrq.gov/node/47827/psn-pdf
February 27, 2019 - Improving Usability, Safety and Patient Outcomes With
Health Information Technology.
February 27, 2019
Lau F, Bartle-Clar JA, Bliss G, et al, eds. Stud Health Technol Inform. 2019;257:1-539. ISBN:
9781614999508.
https://psnet.ahrq.gov/issue/improving-usability-safety-and-patient-outcomes-health-information-technol…
-
psnet.ahrq.gov/node/41203/psn-pdf
December 18, 2014 - A multicenter collaborative approach to reducing
pediatric codes outside the ICU.
December 18, 2014
Hayes LW, Dobyns EL, DiGiovine B, et al. A multicenter collaborative approach to reducing pediatric codes
outside the ICU. Pediatrics. 2012;129(3):e785-91. doi:10.1542/peds.2011-0227.
https://psnet.ahrq.gov/issue/mu…