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7141. Chapter 1. The Framework for Improvement | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide1.html
      February 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism Chapter 1. The Framework for Improvement Previous Page Next Page Table of Contents Preventing Hospital-Associated Venous Thromboembolism Preface Executive Summary Chapter 1. The Framework for Improvement Chapter 2. Analyze Care Delivery …

7142. Ldusafety Facguide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.docx
      May 01, 2017 - AHRQ Safety Program for Perinatal Care Labor and Delivery Unit Safety Labor and Delivery Unit Safety SAY: The “Labor and Delivery Unit Safety” bundle provides information on the key safety elements concerning four specific situations encountered in labor and delivery, and the importance of a comprehensive unit-based …

7143. Labor and Delivery Unit Safety: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety-fac-guide.html
      July 01, 2023 - Labor and Delivery Unit Safety: Facilitator Guide AHRQ Safety Program for Perinatal Care Slide 1: Labor and Delivery Unit Safety Say: The “Labor and Delivery Unit Safety” bundle provides information on the key safety elements concerning four specific situations encountered in labor and delivery, and the…

7144. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/838351
      July 01, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Diagnostic Safety Improvement Curated Library Foundations Improving Diagnosis in Health Care. Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; …

7145. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency | PSNet
      psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
      May 01, 2018 - SPOTLIGHT CASE Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency Citation Text: Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…

7146. Hypoxemia after Emergency Intubation | PSNet
      psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
      March 24, 2019 - Hypoxemia after Emergency Intubation Citation Text: Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…

7147. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/865308
      January 01, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Organizational Learning Curated Library Foundations Organizational learning: health care leaders need to design structures and processes that enhance collective learning. Bohmer RM, Edmondson AC. Health Forum J. 2001;44:32-35. This comment…

7148. Do Not Disturb! | PSNet
      psnet.ahrq.gov/web-mm/do-not-disturb
      February 03, 2011 - SPOTLIGHT CASE Do Not Disturb! Citation Text: Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

7149. Value and Patient Safety | PSNet
      psnet.ahrq.gov/curated-library/value-and-patient-safety
      October 30, 2019 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Value and Patient Safety  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Tea…

7150. Guides for PSOs and Providers for Determining Parent Organizations and Affiliated Providers (pdf file)
      pso.ahrq.gov/sites/default/files/wysiwyg/guides-psos-providers-determining-parent-orgs-affiliated-providers.pdf
      July 01, 2021 - Guides for PSOs and Providers for Determining Parent Organizations and Affiliated Providers GUIDE FOR PSOS AND PROVIDERS FOR DETERMINING PARENT ORGANIZATIONS AND AFFILIATED PROVIDERS Determining Which Entities Meet the Patient Safety Rule’s Definition of Parent Organization Background The Patient Safety Ru…

7151. The Challenge and Potential for Assuring Quality Health Care for the 21st Century | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/quality-measures/21st-century/index.html
      June 01, 2018 - The Challenge and Potential for Assuring Quality Health Care for the 21st Century Next Page Table of Contents The Challenge and Potential for Assuring Quality Health Care for the 21st Century From Quality Measures to Quality Care: Examples of Quality Improvement at Work Private Sector Efforts in V…

7152. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851099/psn-pdf
      June 28, 2023 - Misconnection Leading to Arterial Thrombosis June 28, 2023 Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis The Case A 55-year-old man with chronic obstructive pulmonary disease (COPD) was brought by am…

7153. Implementation of Patient Safety Projects | PSNet
      psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
      September 15, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Implementation of Patient Safety Projects  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybraria…

7154. Final Progress Report: Reducing Risks by Engineering Resilience Into HIT for EDs (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/wears-report.pdf
      January 01, 2024 - Final Progress Report: Reducing Risks by Engineering Resilience Into HIT for EDs Reducing Risks by Engineering Resilience into HIT for EDs Principal Investigator: Robert L. Wears, MD, MS, PhD Team Members: John Wreathall Rollin (Terry) Fairbanks, MD, MS Ann M. Bisantz, PhD Shawna J Perry, MD Chris Johnson,…

7155. Lessons from the Field: Measuring Intermediate Progress (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/lessons/lessons-intermediate-progress.pdf
      November 04, 2018 - Lessons from the Field: Measuring Intermediate Progress Lessons from the Field: Measuring Intermediate Progress Prepared for the Agency for Healthcare Research and Quality by L&M Policy Research, LLC with guidance from the Pediatric Quality Measure Program (PQMP) Grantees i Table of Contents List of Acrony…

7156. Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
      January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx Spotlight Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See…

7157. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
      January 01, 2022 - Spotlight Spotlight Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong Source and Credits • This presentation is based on the October 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary…

7158. Auditing Your Briefings and Debriefings Process: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/implementation/audit-briefing-fac-notes.html
      December 01, 2017 - Auditing Your Briefings and Debriefings Process: Facilitator Notes AHRQ Safety Program for Surgery Slide 1: Auditing Your Briefing and Debriefing Process Say: Let’s continue our discussion around briefings and debriefings. The previous module, Optimizing Your Briefings and Debriefings, focused on defini…

7159. Facilitator Guide: Auditing Your Briefings and Debriefings (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_audit_briefing_facnotes.docx
      December 01, 2017 - Facilitator Guide: Auditing Your Briefings and Debriefings Slide Title and Commentary Slide Number and Slide Auditing Your Briefing and Debriefing Process SAY: Let’s continue our discussion around briefings and debriefings. The previous module, Optimizing Your Briefings and Debriefings, focused on defining them…

7160. Learn From Defects Tool—Perioperative Setting | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/learn-from-defects.html
      December 01, 2017 - Learn From Defects Tool—Perioperative Setting AHRQ Safety Program for Surgery What is a defect? A defect is any event or situation that you don’t want to repeat. This could include an incident that caused patient harm or put patients at risk for harm, such as a patient fall. Problem statement: …