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  1. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/sustaining-change-transcript.docx
    April 14, 2015 - April 14, 2015 Sustaining Change Speaker 1: The following is a recording for [Cathy Drury 00:00:02], with the American Hospital Association in Chicago, for the April National conference 00:00:06 call on Tuesday, April 14, 2015 at 11 a.m. central time. Excuse me everyone. We now have all of our speakers in conference. P…
  2. www.ahrq.gov/research/findings/nhqrdr/chartbooks/access/access-slides.html
    June 01, 2018 - Access to Health Care Chartbook: Slide Presentation National Healthcare Quality and Disparities Report Slide 1 National Healthcare Quality and Disparitites Report Chartbook on Access to Health Care May 2016 Slide 2 National Healthcare Quality and Disparities Report Annual report to Congress m…
  3. www.ahrq.gov/sites/default/files/2024-07/congdon-magilvy-report.pdf
    January 01, 2024 - Final Progress Report: Quality Factors in Nursing Home Choice 1 Title Page Title of Project: Quality Factors in Nursing Home Choice Principal Investigator: JoAnn G. Congdon Team Members: Co-Principal Investigator: Joan K. Magilvy Investigator: Mary A. Blegen Investigator: Katherine R. Jones Investigator: Nor…
  4. www.ahrq.gov/sites/default/files/2024-01/gurwitz-report.pdf
    January 01, 2024 - Final Progress Report: Enhancing the Safety of Warfarin in the Nursing Home Project Title: Enhancing the Safety of Warfarin in the Nursing Home Principal Investigator: Jerry H. Gurwitz, MD Principal Team Members: Jerry Gurwitz, MD; Terry S. Field, DSc; Jennifer Tjia, MD, MSCE; Kathleen M. Mazor, EdD; Leslie R. Ha…
  5. www.ahrq.gov/sites/default/files/2024-02/zierler-report.pdf
    January 01, 2024 - Final Progress Report: VTE Safety Toolkit: A Systems Approach to Patient Safety Title: VTE Safety Toolkit: A Systems Approach to Patient Safety Principal Investigator: Brenda K. Zierler, PhD1 Team Members: Ann Wittkowsky, PharmD2 Robb Glenny, MD3 Seth Wolpin, PhD1 Jung-Ah Lee, MN1 Gene Peterson, MD, PhD3 Fre…
  6. www.ahrq.gov/sites/default/files/2024-01/muller-report.pdf
    January 01, 2024 - Final Progress Report: Medication Reconciliation: Bridging Communications Across the Continuum of Care Title: Medication Reconciliation: Bridging Communications Across the Continuum of Care Principal Investigator and Team Members: Melinda Muller, MD, Lynn Belcher, RPh, Melissa Blanchard, MP, Amy Caster-Winegeart, …
  7. www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/addressing-workforce-safety-062723.pdf
    July 25, 2023 - The National Action Alliance to Advance Patient Safety Summer Webinar Series: CDC Presentation The National Action Alliance to Advance Patient Safety Summer Webinar Series Addressing Violence in the Workplace June 27, 2023 2:00-3:00 PM ET Special Guest Speakers 2 Martin Hatlie, JD President & CEO, Project P…
  8. www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-131-section-5-table-8-9.pdf
    January 01, 2013 - Section 5, Tables 8 and 9 …
  9. www.ahrq.gov/sites/default/files/2024-04/ratliff-report.pdf
    January 01, 2024 - Final Progress Report: Developing a patient-centered model of the risk of perioperative complications in spine surgery Developing a patient-centered model of the risk of perioperative complications in spine surgery John Ratliff, MD, PI Team members: Summer Han, PhD Richard Olshen, PhD Lu Tian, PhD Paola Suarez …
  10. www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/about/2014cahpshealthplanchartbook.pdf
    October 01, 2014 - 2014 CAHPS Health Plan Survey Database Chartbook THE CAHPS DATABASE 2014 CAHPS Health Plan Survey Database 2014 Chartbook: What Consumers Say About Their Experiences with Their Health Plans and Medical Care AHRQ Contract No.: HHSA290201300003C Managed and prepared by: Westat, Rockville, MD Dale Shalle…
  11. www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2014_hp-chartbook.pdf
    January 01, 2014 - 2014 CAHPS Health Plan Survey Database Chartbook THE CAHPS DATABASE 2014 CAHPS Health Plan Survey Database 2014 Chartbook: What Consumers Say About Their Experiences with Their Health Plans and Medical Care AHRQ Contract No.: HHSA290201300003C Managed and prepared by: Westat, Rockville, MD Dale Shalle…
  12. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
    January 01, 2003 - Do Transient Working Conditions Trigger Medical Errors? 53 Do Transient Working Conditions Trigger Medical Errors? Deborah Grayson, Stuart Boxerman, Patricia Potter, Laurie Wolf, Clay Dunagan, Gary Sorock, Bradley Evanoff Abstract Objective: Organizational factors affecting working conditions for health …
  13. www.ahrq.gov/sites/default/files/2025-03/hinson-levin-report.pdf
    January 01, 2025 - Final Progress Report: Connected Emergency Care (CEC) Patient Safety Learning Lab • Title of Project: Connected Emergency Care (CEC) Patient Safety Learning Lab • Principal Investigators: Jeremiah S. Hinson, MD, PhD, and Scott R. Levin, PhD • Team Members: Jeremiah Hinson, MD, PhD, Scott Levin, PhD, Eili Klein, Ph…
  14. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
    January 01, 2004 - Diagnostic Failure: A Cognitive and Affective Approach 241 Diagnostic Failure: A Cognitive and Affective Approach Pat Croskerry Abstract Diagnosis is the foundation of medicine. Effective treatment cannot begin until an accurate diagnosis has been made. Diagnostic reasoning is a critical aspect of clinic…
  15. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
    June 30, 2004 - Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative 133 Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative Daniel M. Harris, John M. Westfall, Douglas H. Fernald, Christine W. Duclos, David R. West, Linda Niebauer, Linda Ma…
  16. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
    April 22, 2004 - Work System Analysis: The Key to Understanding Health Care Systems 337 Work System Analysis: The Key to Understanding Health Care Systems Ben-Tzion Karsh, Samuel J. Alper Abstract Many articles in the medical literature state that medical errors are the result of systems problems, require systems analyses, a…
  17. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Hundt.pdf
    January 01, 2003 - Outpatient Surgery and Patient Safety—The Patient’s Voice 445 Outpatient Surgery and Patient Safety— The Patient’s Voice Ann Schoofs Hundt, Pascale Carayon, Scott Springman, Maureen Smith, Kelly Florek, Rupa Sheth, Margaret Dorshorst Abstract Four outpatient surgery centers from a large Midwestern communit…
  18. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Ehringer_17.pdf
    February 08, 2008 - Promoting Best Practice and Safety Through Preprinted Physician Orders Promoting Best Practice and Safety Through Preprinted Physician Orders George Ehringer, MD; Barbara Duffy, RN, LHRM, MPH Abstract Defining how preprinted physician orders are developed within a hospital has the potential to positi…
  19. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
    April 07, 2008 - Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures Stanley Davis, MD; William Riley, PhD; Ayse P. Gurses, PhD; Kr…
  20. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Zierler_81.pdf
    September 01, 2008 - Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety Brenda K. Zierler, PhD; Ann Wittkowsky, PharmD; Gene Peterson, MD, PhD; Jung-Ah Lee, MN; Courtney Jacobson, BA; Robb Glenny, MD; Fred Wolf, PhD; Lynne Robin…

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