-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_shoulder-dystocia.docx
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Shoulder Dystocia
AHRQ Safety Program for Perinatal Care
Labor and Delivery Unit Safety
Shoulder Dystocia
Labor and Delivery Unit Safety—Shoulder Dystocia
Purpose of the tool: This tool describes the key perinatal safety elements related to the saf…
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/podcasts/Teamwork_in_QI_2012_02_01_Transcript.pdf
January 01, 2012 - the skills that they bring to be able to actually engage and elevate
that care team to the highest skill
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/literacy/about_the_health_literacy_item_set_for_hospitals_911.pdf
October 01, 2015 - About the CAHPS® Health Literacy Item Set for Hospitals
CAHPS® Adult Hospital Survey: Supplemental Items
About the CAHPS Health Literacy Item Set for Hospitals
Document No. 911
10/01/2015
About the CAHPS® Health Literacy Item
Set for Hospitals
Introduction...............................................…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
June 02, 2025 - Complex wound management, for example, not only requires specific staff knowledge and skill but also
-
www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
December 01, 2017 - Learning From Defects Through Sensemaking: Slide Presentation
AHRQ Safety Program for Surgery
Slide 1: AHRQ Safety Program for Surgery—Implementation
Learning From Defects through Sensemaking
Slide 2: Learning Objectives
Describe difference between first-order and second-order problem-solving.
L…
-
psnet.ahrq.gov/node/49712/psn-pdf
June 01, 2014 - May I Have Another?—Medication Error
June 1, 2014
Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
The Case
A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a
pharmacology-tra…
-
psnet.ahrq.gov/node/33664/psn-pdf
March 01, 2008 - 5, 10, or 15, you may or may not really know what you're doing; and second, you may never need the skill
-
psnet.ahrq.gov/node/33746/psn-pdf
March 01, 2013 - In Conversation With… David M. Gaba, MD
March 1, 2013
In Conversation With… David M. Gaba, MD. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
Editor's note: David M. Gaba, MD, is a Professor of Anesthesia at the Stanford University School of
Medicine. An international leade…
-
psnet.ahrq.gov/node/49829/psn-pdf
May 01, 2018 - Root Cause Analysis Gone Wrong
May 1, 2018
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
The Case
A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney
transplant. A suitabl…
-
psnet.ahrq.gov/node/33806/psn-pdf
April 01, 2016 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
Editor's note: Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of
Pediatrics a…
-
psnet.ahrq.gov/web-mm/standard-deviations
January 01, 2006 - SPOTLIGHT CASE
Standard Deviations
Citation Text:
Sabin JE. Standard Deviations. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
-
psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - Failure to Rescue the Mother
Citation Text:
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote…
-
psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - Root Cause Analysis Gone Wrong
Citation Text:
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML E…
-
digital.ahrq.gov/sites/default/files/docs/citation/r01hs021681-zikmund-fisher-final-report-2017.pdf
January 01, 2017 - Systematic Design of Meaningful Presentations of Medical Test Data for Patients - Final Report
Final Progress Report
November 16, 2017
Title: Systematic Design of Meaningful Pre…
-
psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - SPOTLIGHT CASE
Discharged with IV antibiotics: When issues arise, who manages the complications?
Citation Text:
Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
-
psnet.ahrq.gov/node/836839/psn-pdf
March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare
Staff
March 31, 2022
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
Introduction
The…
-
www.ahrq.gov/sites/default/files/2025-03/fenton-report.pdf
January 01, 2025 - delivered by standardized patient instructors
(SPIs) that was designed to boost primary care clinician skill
-
effectivehealthcare.ahrq.gov/sites/default/files/eaagleston.pdf
October 08, 2025 - be suitable for the app format, you know, and it should represent,
you know, your expertise, your skill
-
psnet.ahrq.gov/issue/learning-adverse-events-and-near-misses
January 15, 2020 - Commentary
Learning from adverse events and near misses.
Citation Text:
Greenberg CC. Learning from adverse events and near misses. J Gastrointest Surg. 2009;13(1):3-5. doi:10.1007/s11605-008-0693-6.
Copy Citation
Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML En…
-
psnet.ahrq.gov/issue/clinical-cognition-and-biomedical-informatics-issues-patient-safety
September 04, 2024 - Commentary
Clinical cognition and biomedical informatics: issues of patient safety.
Citation Text:
Patel VL, Currie L. Clinical cognition and biomedical informatics: Issues of patient safety. Int J Med Inform. 2005;74(11-12). doi:10.1016/j.ijmedinf.2005.07.009.
Copy Citation
Form…