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psnet.ahrq.gov/issue/improving-safety-and-security-veterans-act-2020
March 25, 2020 - Legislation/Case Law
Improving Safety and Security for Veterans Act of 2020.
Citation Text:
Improving Safety and Security for Veterans Act of 2020. HB 5616, 116th Congress: 2020.
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psnet.ahrq.gov/issue/perfect-possible
March 06, 2005 - Newspaper/Magazine Article
Perfect is possible.
Citation Text:
Perfect is possible. Berwick DM, Leape LL.
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digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/BenchmarkingQuestions.pdf
January 01, 2010 - Benchmarking Questions
Benchmarking questions
primarily related to workflow
The following questions can be used to better understand others’ experiences with the health IT
system or vendor and the impact or consequences of the health IT on workflow postimplementation.
General questions regarding implemen…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/problem
January 01, 2023 - Problem Solving
Kepner-Tregoe Matrix
Description
A Kepner-Tregoe matrix is used to find causes of a problem. It isolates the who, what, when, where, and how aspects of an event, keeping the focus on the elements that have an impact on the event and eliminating the elements tha…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/data-display
January 01, 2023 - Data Display and Organization
Event Tree Analysis
Description
An event tree analysis (ETA) examines the different paths that can be taken in a given scenario. Each step consists of a node and corresponding exit lines for each possible outcome at that step. The tool was origina…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/task-analysis
January 01, 2023 - Task Analysis
Tabular Task Analysis
Description
A tabular task analysis (TTA) is conducted to evaluate a task or scenario with regard to the necessary task steps and the interface used. The analysis evaluates specific elements of the bottom-level task steps within a hierarch…
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psnet.ahrq.gov/issue/practitioners-agree-medication-reconciliation-value-frustration-and-difficulties-abound
August 09, 2023 - Newspaper/Magazine Article
Practitioners agree on medication reconciliation value, but frustration and difficulties abound.
Citation Text:
Practitioners agree on medication reconciliation value, but frustration and difficulties abound. ISMP Medication Safety Alert! Acute care edition. Ju…
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psnet.ahrq.gov/issue/cms-seeks-add-9-hospital-acquired-conditions-no-pay-list
November 10, 2010 - Newspaper/Magazine Article
CMS seeks to add 9 hospital-acquired conditions to no-pay list.
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May 24, 2015
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psnet.ahrq.gov/issue/assessing-effectiveness-quality-improvement-strategies-europe-marquis-project
January 28, 2015 - Special or Theme Issue
Assessing the effectiveness of quality improvement strategies in Europe: the MARQuIS project.
Citation Text:
Assessing the effectiveness of quality improvement strategies in Europe: the MARQuIS project. Qual Saf Health Care. 2009;18(suppl 1):i1-i80.
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psnet.ahrq.gov/issue/video-games-can-help-cut-surgical-errors
January 23, 2008 - Newspaper/Magazine Article
Video games can help cut surgical errors.
Citation Text:
Video games can help cut surgical errors. Baertlein L.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod2.html
March 01, 2019 - Module 2: Communicating Change in a Resident's Condition
Next Page
Table of Contents
Module 2: Communicating Change in a Resident's Condition
Learning and Performance Objectives
Session 1
Session 2
Conclusion
Additional Tools and Resources
Appendix. Example of the SBAR and CUS Tools
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psnet.ahrq.gov/issue/what-safety-science
January 22, 2022 - Commentary
What is safety science?
Citation Text:
Aven T. What is safety science? Safety Sci. 2014;67:15-20. doi:10.1016/j.ssci.2013.07.026.
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Format:
DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/issue/giving-back-pen-disclosure-apology-and-early-compensation-discussions-after-harm-healthcare
April 26, 2012 - Commentary
Giving back the pen: disclosure, apology and early compensation discussions after harm in the healthcare setting.
Citation Text:
Giving back the pen: disclosure, apology and early compensation discussions after harm in the healthcare setting. Pelletier E, Robson. Healthc Q…
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hcup-us.ahrq.gov/reports/factsandfigures/2007/pdfs/section5_5.pdf
January 01, 2007 - HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2007 61
EXHIBIT 5.5 Costs by Payer
$10,800
$7,900
$7,100
$6,600
0
2,000
4,000
6,000
8,000
10,000
12,000
Medicare Private Insurance Uninsured* Medicaid
A
ve
ra
ge
C
o
st
Average Cost per Discharge by Payer, 2007
*I…
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psnet.ahrq.gov/issue/communicating-critical-test-results-0
November 19, 2014 - Toolkit
Communicating Critical Test Results.
Citation Text:
Communicating Critical Test Results. Burlington MA: Massachusetts Coalition for the Prevention of Medical Errors, MassPRO.
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digital.ahrq.gov/sites/default/files/docs/resource/PCC_Adams_Q3_Smoking_Assessment_Script_06_23_08.pdf
June 16, 2021 - SMOKING (PRE-VISIT CALL, ASSESSMENT)
SMOKING (PRE-VISIT CALL, ASSESSMENT)
NEED TO CREATE THESE VARIABLES:
Variable indicating that parent is a smoker.
Variable recording that they've set goal to call quit line.
Line # Desc Age Group PHP Text
Smoke Q 01 SmokeIntro ALL
PHP, PHP
+ C
The next set of q…
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psnet.ahrq.gov/issue/digital-healthcare-research
December 24, 2008 - Multi-use Website
Digital Healthcare Research.
Citation Text:
Digital Healthcare Research. Agency for Healthcare Research and Quality.
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psnet.ahrq.gov/issue/critical-care-safety-essentials-icu-patient-care-and-technology
March 10, 2021 - Book/Report
Critical Care Safety: Essentials for ICU Patient Care and Technology.
Citation Text:
Critical Care Safety: Essentials for ICU Patient Care and Technology. Plymouth Meeting PA: ECRI Institute; 2007. ISBN 9780977914258.
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www.ahrq.gov/news/newsroom/case-studies/201514.html
June 01, 2015 - New York Hospital Uses AHRQ Resources to Improve Patients' Experience of Care
Search All Impact Case Studies
June 2015
Adoption of AHRQ's TeamSTEPPS® patient safety training program at the 233-bed Northern Westchester Hospital in Mount Kisco, New York, has enhanced communication and teamwork among clinica…
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psnet.ahrq.gov/issue/use-only-directed-isnt-easy
August 17, 2016 - Newspaper/Magazine Article
'Use only as directed' isn't easy.
Citation Text:
'Use only as directed' isn't easy. Landro L.
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