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8401. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47081/psn-pdf
      September 02, 2018 - Beyond Dr. Google: the evidence on consumer-facing digital tools for diagnosis. September 2, 2018 Millenson ML, Baldwin JL, Zipperer L, et al. Beyond Dr. Google: the evidence on consumer-facing digital tools for diagnosis. Diagnosis (Berl). 2018;5(3):95-105. doi:10.1515/dx-2018-0009. https://psnet.ahrq.gov/issue/b…

8402. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74093/psn-pdf
      November 17, 2021 - Prevent errors during emergency use of hypertonic sodium chloride solutions. November 17, 2021 ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4. https://psnet.ahrq.gov/issue/prevent-errors-during-emergency-use-hypertonic-sodium-chloride-solutions Delays in diagnosis and treatment duri…

8403. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46512/psn-pdf
      August 17, 2018 - The problem with using patient complaints for improvement. August 17, 2018 de Vos MS, Hamming JF, van de Mheen PJM-. The problem with using patient complaints for improvement. BMJ Qual Saf. 2018;27(9):758-762. doi:10.1136/bmjqs-2017-007463. https://psnet.ahrq.gov/issue/problem-using-patient-complaints-improvement …

8404. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838192/psn-pdf
      September 28, 2022 - When medical error becomes personal, activism becomes painful. September 28, 2022 Millenson M. Forbes. September 16, 2022. https://psnet.ahrq.gov/issue/when-medical-error-becomes-personal-activism-becomes-painful Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm w…

8405. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72505/psn-pdf
      November 25, 2020 - The second victim phenomenon in health care: a literature review. November 25, 2020 Nydoo P, Pillay BJ, Naicker T, et al. The second victim phenomenon in health care: a literature review. Scand J Public Health. 2020;48(6):629-637. doi:10.1177/1403494819855506. https://psnet.ahrq.gov/issue/second-victim-phenomenon-…

8406. COVID-19 Identification & Prevention series | Agency for Healthcare Research and Quality
      www.ahrq.gov/nursing-home/learning-modules/covid-id-prevention.html
      December 01, 2022 - COVID-19 Identification & Prevention series This series of three learning modules focuses on identifying the signs and symptoms of COVID-19, knowing when and how to report signs and symptoms of COVID-19, and remembering to maintain infection prevention processes. Module 1: COVID-19 Identification and Preventi…

8407. Heart of Virginia Healthcare Primary Care Recruitment Package | Agency for Healthcare Research and Quality
      www.ahrq.gov/evidencenow/projects/urinary/resources/primary-care-recruitment.html
      January 01, 2019 - Back to MUI Resources Heart of Virginia Healthcare Primary Care Recruitment Package Resource Document available on the AHRQ website (PDF, 7.3 MB) Summary This resource is an example of an in-depth recruitment package for primary care practices; it provides background on the r…

8408. Fillable Plan Do Study Act (PDSA) Tool for Health Care Quality Improvement (QI) | Agency for Healthcare Research and Quality
      www.ahrq.gov/evidencenow/tools/pdsa-form.html
      November 01, 2018 - Fillable Plan Do Study Act (PDSA) Tool for Health Care Quality Improvement (QI) Resource: Plan Do Study Act (PDSA) Form  (PDF, 971 KB, 2 pages) Practices can use this fillable Plan Do Study Act (PDSA) tool to design and test changes to improve health care quality. Using this form can be helpful to primary c…

8409. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43232/psn-pdf
      June 04, 2014 - Standardization in patient safety: the WHO High 5s project. June 4, 2014 Leotsakos A, Zheng H, Croteau R, et al. Standardization in patient safety: the WHO High 5s project. Int J Qual Health Care. 2014;26(2):109-16. doi:10.1093/intqhc/mzu010. https://psnet.ahrq.gov/issue/standardization-patient-safety-who-high-5s-…

8410. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47885/psn-pdf
      May 01, 2019 - Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital. May 1, 2019 Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236. https://psnet.ahrq.gov/issue/deny-dismiss-dehumanise-what-happened-when-i-went-hospital Patient stories offer important insights regarding the impact m…

8411. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842779/psn-pdf
      January 12, 2011 - Resilience Engineering in Practice: a Guidebook. January 12, 2011 Hollnagel E, Parie?s J, Woods DD et al eds. Farnham UK; Ashgate, 2011. ISBN: 9781472420749 https://psnet.ahrq.gov/issue/resilience-engineering-practice-guidebook Safety-critical industries rely on organizational aptitude to respond to disr…

8412. Learning from Patient Narratives Through Innovative Feedback Reporting Methods Webcast - NYP Leadership Perspectives (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/learning_pt_narratives_053123-evans.pdf
      June 02, 2025 - Learning from Patient Narratives Through Innovative Feedback Reporting Methods Webcast - NYP Leadership Perspectives NYP Leadership Perspectives Rick Evans Chief Experience Officer New York-Presbyterian Hospital Perspectives from Leadership – Use of Narratives • Adds richer color to “score data” • Compelling…

8413. Emerging Technologies | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/healthit-ed-5.html
      February 01, 2021 - Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments Emerging Technologies Previous Page Next Page Table of Contents Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments Introduction Elect…

8414. Action Planning for the SOPS™ Surveys Infographic (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/action-planning-webcast-graphic.pdf
      February 01, 2019 - Action Planning for the SOPS™ Surveys Infographic Action Planning for the SOPSTM  Surveys January 2019 Webcast Highlights AHRQ's Surveys on Patient Safety CultureTM(SOPS TM) Action Planning Tool guides survey users seeking to improve patient safety culture through the action planning process. The Action Plann…

8415. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848827/psn-pdf
      May 10, 2023 - TQIP Mortality Reporting System Case Reports. May 10, 2023 ACS TQIP Mortality Reporting System Writing Group. J Trauma Acute Care Surg. 2023. https://psnet.ahrq.gov/issue/tqip-mortality-reporting-system-case-reports Anonymous case reporting provides opportunities to examine unexpected patient harm instances to pin…

8416. Exhibit 6.9. Lean Project Roles Mapped to Functional Roles | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit6-9.html
      November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 6.9. Lean Project Roles Mapped to Functional Roles Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Healthcare …

8417. Exhibit 7. Interviews by Position in Organization | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit7.html
      November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 7. Interviews by Position in Organization 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. C…

8418. Exhibit 1.11. Project Team Composition—Bed Flow Project at Each Hospital | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit1-11.html
      November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 1.11. Project Team Composition—Bed Flow Project at Each Hospital Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview…

8419. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/worksheet.docx
      May 01, 2017 - AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership AHRQ Safety Program for Perinatal Care Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership Purpose: To enhance communication and shared problem solving between clinic…

8420. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838031/psn-pdf
      September 13, 2022 - Addressing the Loss of Trust in Safety Culture. September 7, 2022 Philadelphia, PA: Building Trust and the ABIM Foundation; September 13, 2022.  https://psnet.ahrq.gov/issue/addressing-loss-trust-safety-culture Trust in patient safety processes encourages reporting of concerns, learning from error, and develop…