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www.ahrq.gov/news/events/nac/2015-03-nac/nacmtg0315-minutes.html
July 01, 2015 - The projects will feature multidisciplinary teams and the use of brainstorming and rapid prototyping techniques
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www.ahrq.gov/news/events/nac/2016-07-nac/nacmtg0716-minutes.html
November 01, 2016 - Goldmann suggested exploring the use of data visualization techniques and considering needs of both patients
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
May 01, 2003 - attribute mistakes to failure on the part of the individual provider,
using shame, blame, and fear techniques
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs024274-alcantara-final-report-2024.pdf
January 01, 2024 - Key stakeholders were
identified from national searches and snowball sampling techniques.
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs025502-dixon-final-report-2020.pdf
January 01, 2020 - the study design, sample size, sampling, instruments developed and
administered, and data analysis techniques
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psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
November 18, 2016 - safety; normalization of the topic as a routine component of health care; development of interview techniques
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/deprescribing-protocol.pdf
July 01, 2023 - EHC Protocol: Making Healthcare Safer IV: Deprescribing to Reduce Medication Harms in Older Adults
1
Evidence-based Practice Center Rapid Response Protocol
Project Title: Making Healthcare Safer IV: Deprescribing to
Reduce Medication Harms in Older Adults
1. What is the frequency and severity of har…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-IV-patient-family-engagement.pdf
July 01, 2023 - EHC Protocol: Addressing Social Isolation To Improve Health of Older Adults: A Rapid Evidence Review
Evidence-based Practice Center Rapid Response Protocol
Project Title: Making Healthcare Safer IV: Patient and Family
Engagement
Review Questions
1. What is the frequency and severity of harms addre…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs4-opioid-stewardship-protocol.pdf
July 01, 2023 - EHC Protocol: Making Healthcare Safer IV: Opioid Stewardship
1
Evidence-based Practice Center Rapid Review Protocol
Project Title: Making Healthcare Safer IV: Opioid Stewardship
Review Questions
1. What is the frequency and severity of harms associated with opioid prescribing and ordering?
2. What …
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www.ahrq.gov/sites/default/files/2024-09/kutney-lee-report.pdf
January 01, 2024 - Final Progress Report: Changes in Hospital Care Organization and Outcomes
1. TITLE PAGE
Title: Changes in Hospital Care Organization and Outcomes
Principal Investigator: Ann Kutney-Lee
Team Members: Linda H. Aiken (primary mentor); Jeffrey H. Silber, Mary Naylor, Ivo
Abraham (co-mentors)
Organization: University…
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psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
February 26, 2025 - U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument
Save
Save to your library
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January …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-091013.ppt
January 01, 2010 - Reducing Unecessary Urinary catheter Use in the Emergency Department: How to Implement the Process
The Emergency Department & Catheter Insertions
*
Mohamad Fakih, MD, MPH
St. John Hospital and Medical Center
Lisa Wolf, PhD, RN, CEN, FAEN
Emergency Nurses Association (ENA)
Jeremiah Schuur, MD, MHS, FACEP
Brig…
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psnet.ahrq.gov/node/863308/psn-pdf
February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in
Death During Endoscopy
February 28, 2024
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
The Case
A…
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psnet.ahrq.gov/node/837660/psn-pdf
July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse
Outcomes
July 8, 2022
Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
The Cases
Case 1: A 64-year-old man came in for a routine bron…
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx
Spotlight
Respiratory Distress after Neck Surgery: Two
Cases of Post-Operative Cervical Hematoma
Source and Credits
• This presentation is based on the January 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://…
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www.ahrq.gov/hai/clabsi-tools/guide.html
January 01, 2020 - Guide: Purpose and Use of CLABSI Tools
Purpose of the Tools
These tools are designed to support your efforts to implement evidence-based practices and eliminate central line-associated blood stream infections (CLABSI) in your unit. When used with the Comprehensive Unit-based Safety Program (CUSP) Toolkit, the…
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www.ahrq.gov/hai/tools/surgery/modules/on-boarding/build-ssi-bundle-fac-notes.html
December 01, 2017 - Building Your SSI Prevention Bundle: Facilitator Notes
AHRQ Safety Program for Surgery
Slide 1: Building Your SSI Prevention Bundle
Say:
In this module, you’ll learn about using building a local bundle to reduce surgical site infections.
Slide 2: Learning Objectives
Say:
After reviewing this mod…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_build_ssibundle_facnotes.docx
December 01, 2017 - Facilitator Guide: Building Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Building Your Surgical Site Infection Prevention Bundle
SAY:
In this module, you’ll learn about using building a local bundle to reduce surgical site infections.
Slide 1
Learning Objectives
SA…
-
psnet.ahrq.gov/node/49834/psn-pdf
July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound
and Patient Safety
July 1, 2018
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
Case Objectives
Unders…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load-references.html
May 01, 2024 - Cognitive Load Theory and Its Impact on Diagnostic Accuracy
References
Previous Page
Table of Contents
Cognitive Load Theory and Its Impact on Diagnostic Accuracy
Introduction to Diagnostic Errors
Fundamental Concepts for Understanding Cognitive Load
Interplay Between Cognitive Load and Diag…