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  1. The association between sepsis and potential medical injury among hospitalized patients. | PSNet

    psnet.ahrq.gov/issue/association-between-sepsis-and-potential-medical-injury-among-hospitalized-patients
    July 15, 2014 - Study The association between sepsis and potential medical injury among hospitalized patients. Citation Text: Liu V, Turk BJ, Rizk NW, et al. The association between sepsis and potential medical injury among hospitalized patients. Chest. 2012;142(3):606-613. doi:10.1378/chest.11-2556. …

  2. Impact of a relocation to a new critical care building on pediatric safety events. | PSNet

    psnet.ahrq.gov/issue/impact-relocation-new-critical-care-building-pediatric-safety-events
    May 27, 2020 - Study Impact of a relocation to a new critical care building on pediatric safety events. Citation Text: Furthmiller A, Sahay R, Zhang B, et al. Impact of a relocation to a new critical care building on pediatric safety events. J Hosp Med. 2024;19(5):589-595. doi:10.1002/jhm.13324. Copy…

  3. Best practices for chemotherapy administration in pediatric oncology: quality and safety process improvements (2015). | PSNet

    psnet.ahrq.gov/issue/best-practices-chemotherapy-administration-pediatric-oncology-quality-and-safety-process
    September 23, 2020 - Commentary Best practices for chemotherapy administration in pediatric oncology: quality and safety process improvements (2015). Citation Text: Looper K, Winchester K, Robinson D, et al. Best Practices for Chemotherapy Administration in Pediatric Oncology: Quality and Safety Process Impr…

  4. Disclosure and reporting of surgical complications: a double-edged sword? | PSNet

    psnet.ahrq.gov/issue/disclosure-and-reporting-surgical-complications-double-edged-sword
    December 21, 2014 - Study Disclosure and reporting of surgical complications: a double-edged sword? Citation Text: Stahel PF, Flierl MA, Smith WR, et al. Disclosure and reporting of surgical complications: a double-edged sword? Am J Med Qual. 2010;25(5):398-401. doi:10.1177/1062860610370989. Copy Citati…

  5. Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes. | PSNet

    psnet.ahrq.gov/issue/improving-medication-administration-safety-using-naive-observation-assess-practice-and-guide
    October 06, 2016 - Study Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes. Citation Text: Donaldson N, Aydin C, Fridman M, et al. Improving medication administration safety: using naïve observation to assess practice and g…

  6. Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: a scoping review. | PSNet

    psnet.ahrq.gov/issue/cognitive-bias-during-clinical-decision-making-and-its-influence-patient-outcomes-emergency
    September 21, 2022 - Review Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: a scoping review. Citation Text: Jala S, Fry M, Elliott R. Cognitive bias during clinical decision‐making and its influence on patient outcomes in the emergency depart…

  7. No safety, no quality: synthesis of research on hospital and patient safety (1996-2007). | PSNet

    psnet.ahrq.gov/issue/no-safety-no-quality-synthesis-research-hospital-and-patient-safety-1996-2007
    January 04, 2010 - Review No safety, no quality: synthesis of research on hospital and patient safety (1996-2007). Citation Text: Tzeng H-M, Yin C-Y. No safety, no quality: synthesis of research on hospital and patient safety (1996-2007). J Nurs Care Qual. 2007;22(4):299-306. Copy Citation Format: …

  8. Testing alertness of emergency physicians: a novel quantitative measure of alertness and implications for worker and patient care. | PSNet

    psnet.ahrq.gov/issue/testing-alertness-emergency-physicians-novel-quantitative-measure-alertness-and
    September 01, 2016 - Study Testing alertness of emergency physicians: a novel quantitative measure of alertness and implications for worker and patient care. Citation Text: Ferguson BA, Lauriski DR, Huecker M, et al. Testing Alertness of Emergency Physicians: A Novel Quantitative Measure of Alertness and Imp…

  9. Physician knowledge, attitudes, and behavior related to reporting adverse drug events. | PSNet

    psnet.ahrq.gov/issue/physician-knowledge-attitudes-and-behavior-related-reporting-adverse-drug-events
    September 23, 2020 - Study Classic Physician knowledge, attitudes, and behavior related to reporting adverse drug events. Citation Text: Rogers AS, Israel E, Smith CR, et al. Physician Knowledge, Attitudes, and Behavior Related to Reporting Adverse Drug Events. Arch Intern Med. 201…

  10. Combined SNA and LDA methods to understand adverse medical events | PSNet

    psnet.ahrq.gov/issue/combined-sna-and-lda-methods-understand-adverse-medical-events
    November 15, 2023 - Journal Article Combined SNA and LDA methods to understand adverse medical events Citation Text: Zhu L, Reychav I, McHaney R, et al. Combined SNA and LDA methods to understand adverse medical events. Int J Risk Saf Med. 2019;30(3):129-153. doi:10.3233/JRS-180052. Copy Citation Form…

  11. Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. | PSNet

    psnet.ahrq.gov/issue/enabling-learning-healthcare-system-automated-computer-protocols-produce-replicable-and
    September 23, 2020 - Commentary Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. Citation Text: Morris AH, Stagg B, Lanspa M, et al. Enabling a learning healthcare system with automated computer protocols that produce replicab…

  12. Appendix 2-B. Pre/Post-Test Questions and Answers for Module 2 | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap2b.html
    October 01, 2014 - Improving Patient Safety in Long-Term Care Facilities Appendix 2-B. Pre/Post-Test Questions and Answers for Module 2 Previous Page Next Page Table of Contents Improving Patient Safety in Long-Term Care Facilities Introduction Module 1. Detecting Change in a Resident's Condition Module 2. Commu…

  13. TeamSTEPPS Teamwork Attitudes Questionnaire (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-t-taq-questionnaire.pdf
    June 02, 2025 - TeamSTEPPS Teamwork Attitudes Questionnaire TeamSTEPPS Teamwork Attitudes Questionnaire The TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ) is designed to assess attitudes related to team structure and the four essential skills taught in TeamSTEPPS. The 30-item self- report tool uses 5…

  14. Warm Handoffs: A Guide for Clinicians (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-guide-for-clinicians.pdf
    June 02, 2025 - Warm Handoffs: A Guide for Clinicians Why is it important? Communication breakdowns can result in medical errors. Warm handoffs can help address communication issues and: ■ Engage patients and families and encourage them to ask questions. ■ Allow patients to clarify or correct the information exchanged. ■…

  15. Warm Handoffs: A Guide for Staff (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-guide-for-staff.pdf
    June 02, 2025 - Warm Handoffs: A Guide for Staff Why is it important? Warm handoffs can: ■ Engage patients and families as team members. ■ Allow patients to clarify or correct the information exchanged. ■ Build relationships. ■ Provide a safety check. Guide to Patient and Family Engagement in Primary Care How do I conduc…

  16. A Patient’s Guide to Warm Handoffs (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-patient-guide.pdf
    June 02, 2025 - A Patient’s Guide to Warm Handoffs Why is it important? A warm handoff: ■ Lets you hear what your providers are saying about your health and your plan of care. ■ Encourages you to speak up, ask questions, and join the conversation about your health. ■ Gives you a chance to correct or clarify any information…

  17. Sr-Ldr-Checklist-Spanish (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module2/sr-ldr-checklist-spanish.docx
    June 02, 2025 - Programa de seguridad de la AHRQ para cuidados a largo plazo: HAI/CAUTI Kit de herramientas de seguridad para cuidados a largo plazo Lista de verificación para directivos Objetivo: Brindarles a los directivos una lista de verificación para planificar e implementar proyectos de seguridad y mejora de la calidad para…

  18. Management Practices for Sustainability Module 5: Visual Management | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/visual-slides.html
    June 01, 2017 - Management Practices for Sustainability Module 5: Visual Management Slide 1: Management Practices for Sustainability Module 5: Visual Management Management Practices for Sustainability Module 5: Visual Management Slide 2: A Frontline Management System To Promote Safety Standard Work Image: This imag…

  19. Examples of Technical and Adaptive Solutions for Change | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module2/tools.html
    March 01, 2017 - Examples of Technical and Adaptive Solutions for Change AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Purpose: To provide senior leaders with a deeper explanation of technical and adaptive solutions for change Who should use this tool? Senior leaders (long-term care facility administrator…

  20. Gap Analysis Facilitator's Guide: Appendix B | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apb.html
    August 01, 2022 - Gap Analysis Facilitator's Guide: Appendix B Gap Analysis Structured Interview Questions The Gap Analysis Structured Interview Questions allow the facilitator to lead participants through a set of questions designed to elicit participant views on a variety of key policies and practices. Leadership and Cul…
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