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8941. HIT Resource List (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/healthitresourcelist.pdf
      January 01, 2019 - HIT Resource List Improving Health Information Technology Patient Safety: A Resource List for Users of the AHRQ Health Information Technology Item Set I. Purpose This document provides a list of references to websites and other publicly available practical resources that hospitals can use to implement changes …

8942. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853773/psn-pdf
      September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side. September 27, 2023 Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side The Case A first-year orthopedic surgery resident was consulted…

8943. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49508/psn-pdf
      January 01, 2007 - Language Barrier April 1, 2006 Flores G. Language Barrier. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/language-barrier The Case A previously healthy 10-month-old girl was taken to a pediatrician's office by her monolingual Spanish- speaking parents when they noted that their daughter had generalized we…

8944. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49819/psn-pdf
      February 01, 2018 - Signout Fallout February 1, 2018 Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/signout-fallout Case Objectives Understand the role of communication failures in medical errors and preventable adverse events. Review the evidence in support of handoff improvement pr…

8945. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49501/psn-pdf
      February 03, 2006 - Lost in Transition February 1, 2006 Beach C. Lost in Transition. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/lost-transition Case Objectives Provide an overview of transitions in continuously operating industries Review cognitive error Describe the complex dynamics of transitions in emergency care Pro…

8946. Factors that Impact Perinatal Care Experience and Outcomes: Slide Presentation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/perinatal-care-experience-slides.pdf
      March 06, 2025 - Factors that Impact Perinatal Care Experience and Outcomes: Slide Presentation National Center for Excellence in Primary Care Research Presents Factors that Impact Perinatal Care Experience and Outcomes March 6, 2025 Presented by: Amy G. Cantor MD, MPH, FAAFP Lindsay Kennedy Admon, MD, MSc Mark Allen Clapp, …

8947. Introduction to Daily Care Processes: Evidence Behind Spontaneous Awakening Trials, Spontaneous Breathing Trials, and Head of Bed Elevation: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/technical/intro-daily-care-facguide.html
      February 01, 2017 - Introduction to Daily Care Processes: Evidence Behind Spontaneous Awakening Trials, Spontaneous Breathing Trials, and Head of Bed Elevation: Facilitator Guide AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: Introduction to Daily Care Processes: Evidence Behind Spontaneous Awakening Trials, S…

8948. AHRQ Safety Program for Perinatal Care: Facilitation Instructions for Conducting In Situ Simulations
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation.pptx
      May 01, 2017 - AHRQ Safety Program for Perinatal Care: Facilitation Instructions for Conducting In Situ Simulations AHRQ Safety Program for Perinatal Care Establishing a Program of In Situ Simulations AHRQ Publication No. 17-0003-22-EF May 2017 1 Learning Objectives 2 AHRQ Safety Program for Perinatal Care In Situ Simulation…

8949. Chapter 6. Measure Maps and Profiles (continued, 6) | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6e.html
      June 01, 2014 - Care Coordination Measures Atlas Update Chapter 6. Measure Maps and Profiles (continued, 6) Previous Page Next Page Table of Contents Care Coordination Measures Atlas Update Chapter 1: Background Chapter 2. What is Care Coordination? Chapter 3. Care Coordination Measurement Framework Chapter…

8950. The Forgotten Line | PSNet
      psnet.ahrq.gov/web-mm/forgotten-line
      March 11, 2011 - The Forgotten Line Citation Text: Render ML. The Forgotten Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

8951. Reaction to Dye | PSNet
      psnet.ahrq.gov/web-mm/reaction-dye
      March 01, 2007 - Reaction to Dye Citation Text: Cohan R. Reaction to Dye. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

8952. Final Progress Report: Diagnostic Error in Medicine Conference (pdf file)
      www.ahrq.gov/sites/default/files/2025-04/graber-report.pdf
      January 01, 2025 - Final Progress Report: Diagnostic Error in Medicine Conference Final Progress Report Grant Number 1R13HS018321-01 Project Period 8/1/2009 - 1/31/2010 Conference: Diagnostic Error In Medicine PI: Mark L. Graber, MD SUMMARY: This grant was used in support of “Diagnostic Error in Medicine – 2009,” a 2-day confer…

8953. Scisafetynotes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
      June 02, 2025 - SAY: The “Understand the Science of Safety” module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit discusses the importance of understanding system design, safe design principles, and valuing diverse input from team members. By analyzing patient safety as a science, frontline providers will provide a h…

8954. Slide Presentation - Progress Update: The National Action Alliance for Patient and Workforce Safety—What, Why and How? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/progress-update-2024-slides.pdf
      January 01, 2024 - Slide Presentation - Progress Update: The National Action Alliance for Patient and Workforce Safety—What, Why and How? The National Action Alliance for Patient and Workforce Safety - What, Why, and How? NATIONAL WEBINAR April 23, 2024 Housekeeping Notes • This webinar will be recorded and available for viewing…

8955. Program Evaluation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_8-program-evaluation-speaker-notes.pdf
      July 01, 2023 - Program Evaluation Hospital AIM Team Leads SPPC‐II Program Evaluation Module 8 of 8 SPPC‐II Toolkit JHU & AHRQ for AIM SCRIPT Welcome to Module 8 of the SPPC‐II Teamwork Toolkit. In this module we will discuss aspects related to the evaluation of the program. 1 Hospital AIM Team Leads SPPC‐II…

8956. Summary and Discussion | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily4.html
      July 01, 2018 - Guide to Patient and Family Engagement Summary and Discussion Previous Page Next Page Table of Contents Guide to Patient and Family Engagement Executive Summary Introduction Methods Findings Implications for the Guide Summary and Discussion Next Steps References Appendix A: Draft K…

8957. I. Introduction | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/hotline/intro1.html
      May 01, 2016 - Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events I. Introduction Previous Page Next Page Table of Contents Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events Pr…

8958. Summary of Patient Safety Research Opportunities | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/news-events/summit-research-2020/questions.html
      March 01, 2021 - Summary of Patient Safety Research Opportunities AHRQ Summit and Roundtable on Research Priorities for Patient Safety Improvement Research questions, topics, and key themes that were addressed as part of the Patient Safety Roundtable and Patient Safety Summit included the items listed below. It is important t…

8959. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
      www.ahrq.gov/downloads/pub/advances/vol2/Schiff.pdf
      January 01, 2005 - this patient, several radiologists questioned the adequacy of the study (quality of the infusion plus question … interrupted while talking to the patient or thinking about a diagnosis and forgets to ask a critical question

8960. Redesigning Systems To Improve Teamwork and Quality for Hospitalized Patients: RESET Project Implementation Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reset-guide.pdf
      January 01, 2020 - { Yes { No (Skip to question 13) 7. … { Yes { No (Skip to question 40) 35. Which unit will serve as the SECOND phase I unit? 36.