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digital.ahrq.gov/sites/default/files/docs/citation/r01hs021236-franklin-final-report-2017.pdf
January 01, 2017 - Users are
able to request a push of a snapshot of the department on a time schedule of their choosing
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/ocr-protocol-final_1.pdf
December 18, 2019 - Intervention-related factors that may limit applicability
include dose and re-administration schedule
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015431-brooks-final-report-2007.pdf
January 01, 2007 - The effort is meant to allow
the participating facilities to gradually schedule the needed resources
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psnet.ahrq.gov/node/852698/psn-pdf
August 30, 2023 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to
Increase Safety and Diagnostic Accuracy Innovation
August 30, 2023
https://psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-
diagnostic-accuracy
Summary
Addressing diagnostic errors to improve outcomes and patient safety h…
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psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
June 01, 2007 - Advancing Patient Safety Through State Reporting Systems
Jill Rosenthal, MPH | June 1, 2007
View more articles from the same authors.
Citation Text:
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. Rockville (MD): Agency for…
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www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Ruddick_61.pdf
March 09, 2008 - Using Root Cause Analysis to Reduce Falls in Rural Health Care Facilities
Using Root Cause Analysis to Reduce Falls
in Rural Health Care Facilities
Patricia Ruddick, RN, MSN; Karen Hannah, MBA; Charles P. Schade, MD; Gail Bellamy, PhD;
John Brehm, MD; David Lomely, BA.
Abstract
Prevention of patient falls i…
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hcup-us.ahrq.gov/datainnovations/clinicaldata/AdvisoryCouncilmeeting12032009_rev.pdf
December 31, 2007 - The health information infrastructure in America today . . . .
Agency for Health Care Administration
Florida Center for Health Information and Policy Analysis
AHRQ Pilot Project:
Adding Clinical Data Elements
to Administrative Data
Christopher B. Sullivan, Ph.D.
Bahia Diefenbach, Ph.D.
Florida Agency for He…
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - SPOTLIGHT CASE
The Missing Abscess: Radiology Reads in the Digital Era
Citation Text:
Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation…
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psnet.ahrq.gov/node/837791/psn-pdf
August 05, 2022 - Patient Safety in the Ambulatory Care Setting
August 5, 2022
Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet].
2022.
https://psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
Introduction
There is no way to review the year 2021 in quality and …
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?
Citation Text:
Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
C…
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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking
January 26, 2022
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
Disclosure of Relevant Financial Relationships: As a provider ac…
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Patient Safety Events Involving Opioid
Dose Stacking
Source and Credits
• This presentation is based on the January 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…
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psnet.ahrq.gov/web-mm/weighing-surgical-safety
August 04, 2021 - SPOTLIGHT CASE
Weighing In on Surgical Safety
Citation Text:
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
Copy Citation
Format:
Google Scholar …
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psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - SPOTLIGHT CASE
Medication Reconciliation: Whose Job Is It?
Citation Text:
Poon EG. Medication Reconciliation: Whose Job Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Googl…
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psnet.ahrq.gov/node/49522/psn-pdf
November 01, 2006 - Getting a Good Report Card: Unintended Consequences
of the Public Reporting of Hospital Quality
November 1, 2006
Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of
Hospital Quality. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-…
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digital.ahrq.gov/sites/default/files/docs/page/Crandall.ppt
September 01, 2005 - PowerPoint Presentation
Effective IT Implementation in Health Care
Patient Safety and National Resource Center Annual Conference
June 2005
Donald Crandall, MD, FACS
Trinity Health – Our Communities
Sixth largest tax-exempt health system in the United States
Operating revenues of $5.3 billion
44,000…
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/teamwork-ptsafety-norms-slides.pdf
June 30, 2025 - Improving Safety Using Teamwork and Patient Safety Norms
Creating and Maintaining a Culture of Safety Series
(Session 2)
Improving Safety Using Teamwork and Patient Safety Norms
NATIONAL WEBINAR SERIES
March 18, 2025
Housekeeping Instructions
• This webinar will be recorded and available for viewing on the NAA…
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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx
Spotlight
Under Pressure: Tracheostomy Cuff Over Inflation
Leading to Tissue Necrosis and Cuff Rupture
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
April 01, 2016 - Say:
This presentation will introduce you to Communication and Optimal Resolution,
or the CANDOR process. Some organizations struggle to improve the way they
and their care teams respond to medical harm. The CANDOR process aims to
change that.
Slide 1
Say:
To get started, let’s watch this video.
Video: Do Less…
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www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/summary.html
August 01, 2022 - Demonstration Grants Final Evaluation Report
Executive Summary
Previous Page Next Page
Table of Contents
Demonstration Grants Final Evaluation Report
Executive Summary
Detailed Findings
Evaluation Issues
Contributions to Patient Safety and Medical Liability
Lessons Learned From Implement…