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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Retained Surgical Items: Causation and Prevention
February 26, 2025
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
Background
A retained surgical item (RSI) is a surgical patient safety pro…
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psnet.ahrq.gov/print/pdf/node/848754
January 01, 2025 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Implementation of Patient Safety Projects
Curated Library
Foundations
Leading change: why transformation efforts fail.
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
Kotter, a professor at Harvard Business School, outlines the eight stages …
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/health-plan-5.1-adult-composite-measures.pdf
January 24, 2024 - CAHPS Health Plan Survey 5.1H, Adult Version (Medicaid): Survey on the Experiences with Care of Adults Age 18 and Older, as Submitted to the 2023 AHRQ CAHPS Health Plan Survey Database (n = 42 states)
1
Table CPA-AD. Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Health Plan Survey
5.1H, …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/sustainability/premortem-scorecard-facguide.docx
January 01, 2017 - Facilitator Guide: Tools for Sustainability: Premortem and Scorecard
Slide Title and Commentary
Slide Number and Slide
Tools for Sustainability: Premortem and Scorecard
SAY:
This module will cover sustaining and spreading safety improvements. To preface the sustainability discussions, this module is designed to…
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www.ahrq.gov/sites/default/files/2024-12/reeves-report.pdf
January 01, 2024 - Final Progress Report: Developing a Rational Clinical Approach to the Disposition of TIA Cases in the ED
1
1. TITLE PAGE
April 10th, 2012
Final Report Grant No: 1R03HS017740-01
Project Period: 07/01/2009 – 06/30/2010 (with 1-year no cost extension)
Title: Developing a Rational Clinical Approach to the Dispositio…
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight01.html
March 01, 2019 - How are CHIPRA demonstration States approaching practice-level quality measurement and what are they learning?
Evaluation Highlight No. 1
The National Evaluation of the CHIPRA Quality Demonstration Grant Program
Authors: Grace A. Ferry, Henry T. Ireys, Leslie Foster, Kelly J. Devers, and Lauren Smith
This…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/webinar01/sl_fuzzyset.ppt
May 14, 2013 - AHRQ Slide Template 2004
Advanced Methods in Delivery System Research –
Planning, Executing, Analyzing, and
Reporting Research on
Delivery System Improvement
Webinar #1: Fuzzy Set Analysis
Presenter: Marcus Thygeson, MD
Discussant: Jodi Holtrop, PhD,
Moderator: Michael I. Harrison, PhD
Sponsored by AHRQ’s Deliv…
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www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/webinar01/fuzzysets_slides.html
July 01, 2013 - Webinar #1: Fuzzy Set Analysis (Slide Presentation)
Advanced Methods in Delivery System Research - Planning, Executing, Analyzing, and Reporting Research on Delivery System Improvement
Presenter: Marcus Thygeson, MD Discussant: Jodi Holtrop, PhD Moderator: Michael I. Harrison, PhD Sponsored by AHRQ's Delivery…
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psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
November 25, 2020 - Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.
Citation Text:
Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-260-improved-cancer-outcomes-disposition-comments.pdf
May 22, 2023 - Disposition of Comments_Comparative Effectiveness Review No. 260: Nutrition as Prevention for Improved Cancer Health Outcomes
Comparative Effectiveness Review Disposition of Comments Report
Title: Nutrition as Prevention for Improved Cancer Health Outcomes
Draft report available for public comment…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-David_13.pdf
March 19, 2008 - Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process
Risk Reduction and Systematic Error Management:
Standardization of the Pediatric Chemotherapy
Process
Beverly Ann David, PhD; Ana Rodriguez, PharmD; Stanley W. Marks, MD
Abstract
There is an urgent need to m…
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effectivehealthcare.ahrq.gov/sites/default/files/obesity-horizon-scan-high-impact-1406.pdf
June 01, 2014 - expressed optimism about the potential
for a nonsurgical treatment for obesity, but cited the daily requirements
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psnet.ahrq.gov/issue/dod-should-improve-its-process-clinical-adverse-actions-against-providers
May 16, 2018 - Book/Report
DOD Should Improve Its Process for Clinical Adverse Actions against Providers.
Citation Text:
DOD Should Improve Its Process for Clinical Adverse Actions against Providers. Washington, DC: United States Government Accounting Office; April 11, 2024. Publication GAO-24-106107.
…
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psnet.ahrq.gov/issue/physician-burnout
May 01, 2017 - Book/Report
Physician Burnout.
Citation Text:
Physician Burnout. Rockville, MD: Agency for Healthcare Research and Quality; July 2017. AHRQ Publication No. 17-M018-1-EF.
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psnet.ahrq.gov/issue/fda-updates-vinca-alkaloid-labeling-preparation-intravenous-infusion-bags-only
February 10, 2021 - Press Release/Announcement
FDA updates vinca alkaloid labeling for preparation in intravenous infusion bags only.
Citation Text:
FDA updates vinca alkaloid labeling for preparation in intravenous infusion bags only. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administratio…
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psnet.ahrq.gov/issue/fda-101-how-use-consumer-complaint-system-and-medwatch
February 15, 2024 - Fact Sheet/FAQs
FDA 101: How to Use the Consumer Complaint System and MedWatch.
Citation Text:
FDA 101: How to Use the Consumer Complaint System and MedWatch. FDA Consumer Health Information. Silver Spring, MD: US Food and Drug Administration; February 27, 2009.
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psnet.ahrq.gov/issue/adverse-glycemic-events-and-critical-emergencies
December 14, 2022 - Newspaper/Magazine Article
Adverse glycemic events and critical emergencies.
Citation Text:
Adverse glycemic events and critical emergencies. ISMP Medication Safety Alert! Acute care edition. December 2, 2021;(24)1-4.
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psnet.ahrq.gov/issue/operational-measurement-diagnostic-safety-state-science
February 17, 2021 - Book/Report
Emerging Classic
Operational Measurement of Diagnostic Safety: State of the Science.
Citation Text:
Operational Measurement of Diagnostic Safety: State of the Science. Singh H, Bradford A, Goeschel C. Rockville, MD: Agency for Healthcare Research and…
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psnet.ahrq.gov/issue/advancing-diagnostic-excellence-maternal-health-care-proceedings-workshop-brief
September 12, 2018 - Book/Report
Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.
Citation Text:
Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief. National Academies of Sciences, Engineering, and Medicine. Washington, DC…
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psnet.ahrq.gov/issue/safety-and-quality-perioperative-anesthesia-care
June 15, 2011 - Special or Theme Issue
Safety and Quality in Perioperative Anesthesia Care.
Citation Text:
Safety and Quality in Perioperative Anesthesia Care. Preckel B, ed. Best Pract Res Clin Anaesthesiol. 2021;35(1):1-154.
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