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psnet.ahrq.gov/issue/physician-leadership-key-creating-safer-more-reliable-health-care-system
November 17, 2009 - Newspaper/Magazine Article
Physician leadership is key to creating a safer, more reliable health care system.
Citation Text:
Physician leadership is key to creating a safer, more reliable health care system. Silbaugh BR, Leider HL. Physician Exec. Sept-Oct 2009;35:12, 14-16.
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psnet.ahrq.gov/issue/mind-implementation-gap-persistence-avoidable-harm-nhs
March 04, 2010 - Book/Report
Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS.
Citation Text:
Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS. London UK: Patient Safety Learning: 2022.
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psnet.ahrq.gov/issue/errors-clinical-reasoning-causes-and-remedial-strategies
August 25, 2021 - Commentary
Errors in clinical reasoning: causes and remedial strategies.
Citation Text:
Scott IA. Errors in clinical reasoning: causes and remedial strategies. BMJ. 2009;338:b1860. doi:10.1136/bmj.b1860.
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psnet.ahrq.gov/issue/criminalization-mistakes-nursing
June 13, 2011 - Commentary
The criminalization of mistakes in nursing.
Citation Text:
Philipsen NC. The Criminalization of Mistakes in Nursing. J Nurs Pract. 2011;7(9):719-726. doi:10.1016/j.nurpra.2011.07.004.
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psnet.ahrq.gov/issue/human-factors-patient-safety-innovation
June 09, 2021 - Commentary
Human factors in patient safety as an innovation.
Citation Text:
Carayon P. Human factors in patient safety as an innovation. Appl Ergon. 2010;41(5):657-65. doi:10.1016/j.apergo.2009.12.011.
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www.ahrq.gov/ncepcr/tools/confid-report/app-1.html
March 01, 2016 - Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance
Appendix 1. Advantages of sharing “unblinded” performance data within a team, practice, or network*
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Table of Contents
Confidential Physician Feedback Reports: Designing for Optimal Impact on …
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psnet.ahrq.gov/issue/what-doctors-can-learn-factory-floor
June 13, 2011 - Commentary
What doctors can learn from the factory floor.
Citation Text:
Martyn C. What doctors can learn from the factory floor. BMJ. 2010;340(mar03 3). doi:10.1136/bmj.c1217.
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-2.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 3.2. Grand Hospital Center
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Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
Case 2. Central Hospital…
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psnet.ahrq.gov/issue/how-safe-are-compounded-drugs
May 20, 2020 - Newspaper/Magazine Article
How safe are compounded drugs?
Citation Text:
How safe are compounded drugs? Beyzarov E. Drug Topics. September 18, 2006.
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www.ahrq.gov/pqmp/implementation-qi/toolkit/asthma/key-drivers.html
July 01, 2021 - Pediatric Asthma Emergency Department Use Toolkit
Key Driver Diagram
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Table of Contents
Pediatric Asthma Emergency Department Use Toolkit
Introduction
Overview
About the Measure
Key Driver Diagram
Quality Improvement Strategies
Successful quality impr…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-2.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 4.2. Suntown Hospital
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Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
Case 2. Central Hospital
Ca…
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psnet.ahrq.gov/issue/point-care-medication-error-prevention-best-practices-action
December 24, 2007 - Newspaper/Magazine Article
Point-of-care medication error prevention: best practices in action.
Citation Text:
Point-of-care medication error prevention: best practices in action. Swenson D. Patient Safety Qual Heathc. May/June 2007.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/engage/rfe-brochure.pdf
March 01, 2017 - Resident and Family Engagement: What is it? What are the benefits?
Resident and
Family
Engagement:
What is it?
What are the benefits?
What can I do as a resident
or family member to partner
with staff?
Where can I find more
information?
• Share your concerns, needs, and
observations
• Take an active role in …
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psnet.ahrq.gov/issue/computer-technology-and-clinical-work-still-waiting-godot
October 19, 2022 - Commentary
Computer technology and clinical work: still waiting for Godot.
Citation Text:
Wears RL, Berg M. Computer Technology and Clinical Work. JAMA. 2005;293(10). doi:10.1001/jama.293.10.1261.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/overview.docx
March 01, 2017 - AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Long-Term Care Safety Toolkit Modules
Overview of the Long-Term Care Safety Toolkit Modules and Nursing Home Survey on Patient Safety Culture
The Long-Term Care (LTC) Safety Toolkit is designed to support learning and implementation efforts to improve safety cult…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/engage/leader.html
March 01, 2017 - Resident And Family Engagement: What is my role as a leader?
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
What is resident and family engagement?
Resident and family engagement is one component of person-centered care, a philosophy that recognizes residents as individuals and as partners…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/qi-knowledge-survey.pdf
June 02, 2025 - Quality Improvement Assessment
1
Quality Improvement Assessment
Your name: _________________________________ Practice: _____________________________
We would like to know more about your quality improvement (QI) training and experiences. This information
will be used to tailor our QI training for…
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psnet.ahrq.gov/issue/nurses-role-patient-safety
June 09, 2011 - Commentary
Nurses' role in patient safety.
Citation Text:
Hughes RG, Clancy CM. Nurses' role in patient safety. J Nurs Care Qual. 2009;24(1):1-4. doi:10.1097/NCQ.0b013e31818f55c7.
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psnet.ahrq.gov/issue/actions-renew-focus-safety-culture
July 24, 2024 - Newspaper/Magazine Article
Actions to renew focus on safety culture.
Citation Text:
Actions to renew focus on safety culture. Salvon-Harman J. Healthcare Executive. 2023;39(3):48-49.
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psnet.ahrq.gov/issue/eliminating-insulin-errors-rphs-share-tricks
June 13, 2011 - Newspaper/Magazine Article
Eliminating insulin errors: RPhs share tricks.
Citation Text:
Eliminating insulin errors: RPhs share tricks. Cassell D. Drug Topics. March 20, 2006.
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