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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Learning From Defects
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
Slide Title and Commentary
Slide Number and Slide
Learning From Defects
SAY:
Welcome to this presentation on Learning From Defects as part of an o…
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psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
May 31, 2023 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
Citation Text:
In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation …
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www.ahrq.gov/news/events/nac/2022-05-nac/nacmtg051222-minutes.html
August 01, 2022 - Meeting Minutes, May 2022
Minutes from the May 12, 2022, virtual meeting of the Agency for Healthcare Research and Quality's National Advisory Council.
Contents
Summary
Call to Order and Approval of November 17, 2021, Meeting Summary
Discussion of New Opportunities for AHRQ
Patient-Centered Outcomes R…
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www.ahrq.gov/sites/default/files/wysiwyg/news/events/nac/2022-05-nac/nacmtg051222-minutes.pdf
January 01, 2022 - National Advisory Council (NAC) Virtual Meeting Minutes: May 12, 2022
National Advisory Council, May 12, 2022 Page 1
Agency for Healthcare Research and Quality (AHRQ)
National Advisory Council (NAC)
Virtual Meeting
May 12, 2022
SUMMARY
NAC Members Present
Asaf Bitton, M.D., M.P.H., Ariadne Labs, Bri…
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www.ahrq.gov/news/events/nac/2019-04-nac/nacmtg0419-minutes.html
July 01, 2019 - Meeting Minutes, April 2019
National Advisory Council
Minutes from the April 11, 2019, meeting of the Agency for Healthcare Research and Quality's National Advisory Council.
Contents
Summary
Call to Order and Approval of November 15, 2018, Meeting Summary
AHRQ Accomplishments
Budget Update
Directo…
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psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
July 10, 2024 - In Conversation with...Patrick S. Romano, MD, MPH
November 1, 2010
Citation Text:
In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.In Conversation with...Patrick S. Romano, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - SPOTLIGHT CASE
Prolonged DKA in Pregnancy: A Case of Communication Breakdown.
Citation Text:
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services…
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digital.ahrq.gov/sites/default/files/docs/survey/improving-sickle-cell-transitions-focus-group-moderator-guide-%20it-developers.pdf
June 16, 2021 - Improving Sickle Cell Transitions, Focus Group Moderator Guide: IT Developers
Improving Sickle Cell Transitions, Focus Group Moderator Guide: IT Developers
The Lewin Group, Inc., Falls Church Virginia
This is a focus group guide designed to be conducted with developers across a health care system.
The tool …
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/teamwork-ptsafety-norms-slides.pdf
August 01, 2025 - Improving Safety Using Teamwork and Patient Safety Norms
Creating and Maintaining a Culture of Safety Series
(Session 2)
Improving Safety Using Teamwork and Patient Safety Norms
NATIONAL WEBINAR SERIES
March 18, 2025
Housekeeping Instructions
• This webinar will be recorded and available for viewing on the NAA…
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www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
August 01, 2022 - Grand Rounds Presentation
AHRQ Communication and Optimal Resolution Toolkit
Say:
This presentation will introduce you to Communication and Optimal Resolution, or the CANDOR process. Some organizations struggle to improve the way they and their care teams respond to medical harm. The CANDOR process a…
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www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Ruddick_61.pdf
March 09, 2008 - Using Root Cause Analysis to Reduce Falls in Rural Health Care Facilities
Using Root Cause Analysis to Reduce Falls
in Rural Health Care Facilities
Patricia Ruddick, RN, MSN; Karen Hannah, MBA; Charles P. Schade, MD; Gail Bellamy, PhD;
John Brehm, MD; David Lomely, BA.
Abstract
Prevention of patient falls i…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
April 01, 2016 - Say:
This presentation will introduce you to Communication and Optimal Resolution,
or the CANDOR process. Some organizations struggle to improve the way they
and their care teams respond to medical harm. The CANDOR process aims to
change that.
Slide 1
Say:
To get started, let’s watch this video.
Video: Do Less…
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery
1
Source and Credits
This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Andrew P.J. …
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/patient-safety-technology-resources.pdf
May 01, 2023 - Improving Health Information Technology (IT) Patient Safety: A Resource List for Users of the AHRQ Health Information Technology Supplemental Item Set
SOPS Health IT Patient Safety Supplemental Item Set Resource List 1
Improving Health Information Technology (IT) Patient
Safety: A Resource List for Users of the A…
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hcup-us.ahrq.gov/reports/race/StandAloneR_EExecSum4_28forweb.pdf
March 11, 2011 - Microsoft Word - Stand Alone R-E Exec Sum 4-28 for web.docx
1
STATE DOCUMENTATION OF RACIAL AND ETHNIC HEALTH DISPARITIES TO
INFORM STRATEGIC ACTION: SUMMARY
Nearly a decade ago, the Institute of Medicine (IOM) issued a call to action to redesign
the United States’ health care system because Americans do not …
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psnet.ahrq.gov/perspective/implementing-fall-prevention-program
November 29, 2023 - Implementing a Fall Prevention Program
Frances Healey, RN, PhD | December 1, 2011
View more articles from the same authors.
Citation Text:
Healey F. Implementing a Fall Prevention Program. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
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www.ahrq.gov/sites/default/files/wysiwyg/chsp/news-and-events/events/webinars/chsp-webinar-slides-011221.pdf
January 12, 2021 - Advancing Understanding of Health Care Delivery Using the AHRQ Compendium of U.S. Health Systems
Advancing Understanding of
Health Care Delivery
Using the Compendium of
U.S. Health Systems
January 12, 2021
Presenters
Genna Cohen
Mathematica
Michael Furukawa
Agency for Healthcare
Research and Quality
David J…
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digital.ahrq.gov/sites/default/files/docs/2010-02-24%20Transitions%20In%20Care%20(4).pdf
January 01, 2010 - A National Web Conference on Transitions in Care
Managing Patient Care Transitions: How Health IT
Can Reduce Unnecessary Re‐Hospitalization
February 24, 2010
Presenters:
Stephen Jencks
Independent Consultant In Health Care Safety
Brian Jack
Department of Family Medicine at Boston University School of
…
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psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
June 01, 2015 - SPOTLIGHT CASE
Empiric Steroids: the Good, the Bad, and the Ugly
Citation Text:
Harris ED. Empiric Steroids: the Good, the Bad, and the Ugly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:…
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psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
January 01, 2014 - SPOTLIGHT CASE
Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad
Citation Text:
Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citatio…