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  1. 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…
  2. 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…
  3. 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…
  4. 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…
  5. 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 …
  6. 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…
  7. 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 …
  8. 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…
  9. 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…
  10. 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…
  11. 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…
  12. Psn-Pdf (pdf file)

    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…
  13. 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 …
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. 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 …
  17. 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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…