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  1. 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…
  2. 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 …
  3. 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…
  4. 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…
  5. 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…
  6. 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…
  7. 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…
  8. 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 …
  9. 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…
  10. 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…
  11. 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…
  12. 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…
  13. 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. …
  14. 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…
  15. 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 …
  16. 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…
  17. 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…
  18. 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  …
  19. 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:…
  20. 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…