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  1. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-04/final_april-spotlight-implicit_biases_04.02.2020.pdf
    January 01, 2020 - Spotlight Spotlight Implicit Biases, Interprofessional Communication, and Power Dynamics Source and Credits • This presentation is based on the April 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Erin Stephany Sanchez, MD, Melody Tran- Reina, MD, Kupi…

  2. Spotlight-Slides-Wright-Schiff (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-04/spotlight-slides-wright-schiff.pdf
    January 01, 2020 - Spotlight The Lost Start Date, an Unknown Risk of E-prescribing Source and Credits • This presentation is based on the October 2019 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Adam Wright, PhD, and Gordon Schiff, MD ○ Editor, AHRQ…

  3. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
    January 01, 2020 - Spotlight Spotlight Fatal PCA Opioid-Induced Respiratory Depression Source and Credits • This presentation is based on the May 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP o Editors in Chie…

  4. Roll-Out Diagram Generic (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-09/Roll-out%20diagram%20generic.pdf
    January 01, 2021 - R e si li e n ce P ro g ra m Le a d e r( s) S p e ci fi c D e p t/ U n it Le a d s M e n ta l H e a lt h C o n su lt a n t, i f A v a il a b le How to roll out the Battle Buddy program as part of a psychological resilience intervention Can stand alone* Specific nursing unit le…

  5. Validating domains of patient contextual factors essential to preventing contextual errors: a qualitative study conducted at Chicago area Veterans Health Administration sites. | PSNet

    psnet.ahrq.gov/issue/validating-domains-patient-contextual-factors-essential-preventing-contextual-errors
    September 20, 2011 - preventing contextual errors: a qualitative study conducted at Chicago area Veterans Health Administration sites … Preventing Contextual Errors: A Qualitative Study Conducted at Chicago Area Veterans Health Administration Sites … Preventing Contextual Errors: A Qualitative Study Conducted at Chicago Area Veterans Health Administration Sites

  6. Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study. | PSNet

    psnet.ahrq.gov/issue/effects-multifaceted-medication-reconciliation-quality-improvement-intervention-patient
    April 12, 2023 - However, significant differences existed between the study sites, with sites that successfully implemented

  7. Hospital ward adaptation during the COVID-19 pandemic: a national survey of academic medical centers. | PSNet

    psnet.ahrq.gov/issue/hospital-ward-adaptation-during-covid-19-pandemic-national-survey-academic-medical-centers
    April 12, 2023 - Sites reported rapid expansion of respiratory isolation units (RIUs – dedicated units for patients with … In addition, nearly half of responding sites reported diagnostic errors involving COVID-19 (missing

  8. Indication alerts to improve problem list documentation. | PSNet

    psnet.ahrq.gov/issue/indication-alerts-improve-problem-list-documentation
    July 28, 2021 - Both sites resulted in a proportion of new problems being added to the problem list for the medications … assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43102/psn-pdf
    December 14, 2016 - Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites. … Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites. … psnet.ahrq.gov/issue/diagnostic-errors-interpretation-pediatric-musculoskeletal-radiographs- common-injury-sites … psnet.ahrq.gov/issue/diagnostic-errors-interpretation-pediatric-musculoskeletal-radiographs-common-injury-sites … psnet.ahrq.gov/issue/diagnostic-errors-interpretation-pediatric-musculoskeletal-radiographs-common-injury-sites

  10. AHRQ PSNet Webinar (pdf file)

    psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
    January 01, 2025 - AHRQ PSNet Webinar AHRQ PSNet Webinar Making Healthcare Safer (MHS) IV: Rapid Response Systems and Opioid Stewardship February 10, 2025 Agenda 2 • Logistics • Introduction to the Making Healthcare Safer (MHS) IV Reports • Report 1 – Rapid Response Systems ► Discussion ► PSNet Resources • Report 2 – Opioid …

  11. Adherence to recommended electronic health record safety practices across eight health care organizations. | PSNet

    psnet.ahrq.gov/issue/adherence-recommended-electronic-health-record-safety-practices-across-eight-health-care
    May 20, 2019 - Across the 8 sites, 25 of the 140 recommendations were fully implemented. … assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites

  12. Who applies an intervention to influence cultural attributes in a quality improvement collaborative? | PSNet

    psnet.ahrq.gov/issue/who-applies-intervention-influence-cultural-attributes-quality-improvement-collaborative
    January 22, 2016 - This analysis of data from the Keystone ICU project found that sites with a higher perceived safety climate … The authors found that sites with greater organizational support were more likely to implement the program

  13. A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes. | PSNet

    psnet.ahrq.gov/issue/high-reliability-organization-framework-health-care-multiyear-implementation-strategy-and
    November 17, 2021 - Based on these results, the framework will be implemented across 18 additional VHA sites. … during an in situ simulation intervention: a repeated cross-sectional intervention study at two hospital sites

  14. Problem list completeness in electronic health records: a multi-site study and assessment of success factors. | PSNet

    psnet.ahrq.gov/issue/problem-list-completeness-electronic-health-records-multi-site-study-and-assessment-success
    April 29, 2018 - diagnostic for diabetes), problem list completeness was found to range from 60% to 99% across the 10 sites … The authors conducted interviews with informatics leaders at the four top performing sites to determine

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60181/psn-pdf
    April 01, 2020 - field guides and analytic tools, using a multidisciplinary evaluation team, building trust with the sites … , engaging sites in participatory data collection, rapid team analysis of data sources, and validating … findings with the sites.

  16. A virtual breakthrough series collaborative to support deprescribing interventions across Veterans Affairs healthcare settings. | PSNet

    psnet.ahrq.gov/issue/virtual-breakthrough-series-collaborative-support-deprescribing-interventions-across-veterans
    April 24, 2018 - In this study, 21 Veterans Health Administration (VA) sites developed their own deprescribing protocols … Sites employed decision support tools, such as the VA VIONE tool , and other strategies, such as individualized

  17. The Different Count Contributions to Retention (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
    January 01, 2024 - The Different Count Contributions to Retention Differential Count Contributions in Retained Surgical Sponge Cases: Examination of Administrative Penalty Cases from the California Department of Public Health (CDPH), Health and Safety Code Section 1280.1 Enforcement Reports from 2007-2014 A NoThing Left Behin…

  18. The Patient Safety Perspective: Health Information and Resources Online and In Print, Revised Edition. | PSNet

    psnet.ahrq.gov/issue/patient-safety-perspective-health-information-and-resources-online-and-print-revised-edition
    January 30, 2005 - This bibliography introduces patient safety and provides information about relevant Web sites

  19. Scaling safety: the South Carolina Surgical Safety Checklist experience. | PSNet

    psnet.ahrq.gov/issue/scaling-safety-south-carolina-surgical-safety-checklist-experience
    February 07, 2018 - In this statewide initiative, implementation of the checklist varied significantly among sites. … Sites that invested more funding and time also saw greater checklist implementation.

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866862/psn-pdf
    October 02, 2024 - This mixed methods study compared qualitative data from key informants at four VHA sites with quantitative … qualitative data aligned with most PSC survey domains but identified significant variation across sites
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