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digital.ahrq.gov/sites/default/files/docs/citation/r21hs025443-abraham-final-report-2020.pdf
January 01, 2020 - An Etiology for Medication Ordering Errors in CPOE Systems - Final Report
TITLE PAGE
Title: An Etiology for Medication Ordering Errors in CPOE Systems
Principal Investigator: Joanna Abraham, PhD
Key Team Members: Anthony Faiola, PhD; William Gal…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department
Issue Brief 8
Distributed Cognition and the Role
of Nurses in Diagnostic Safety in the
Emergency Department
PATIENT
SAFETY
e
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e
Issue Brief 8
Distributed Cognition and the Rol…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Kravitz.pdf
February 09, 2005 - From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator
395
From Insight to Implementation:
Lessons from a Multi-site Trial of
a PDA-based Warfarin Dose Calculator
Richard L. Kravitz, Jonathan D. Neufeld, Michael A. Hogarth,
Debora A. Paterniti, William Dager, …
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-appa4.pdf
January 01, 2018 - 2018 National Healthcare Quality and Disparities Report: Appendix A
2018 National Healthcare Quality and Disparities Report | A.4-1
APPENDIX A. LIST OF MEASURES AND SUMMARY OF RESULTS FOR FIGURES
A.4. Disparities: Income
Measures included in Figure 101: Number and percentage of quality measures for which income…
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psnet.ahrq.gov/node/49598/psn-pdf
February 01, 2010 - Medication Reconciliation Pitfalls
February 1, 2010
Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
The Case
A 90-year-old woman who lived alone suffered a mechanical fall with subsequent hip fracture and was
brought to the eme…
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psnet.ahrq.gov/node/33615/psn-pdf
June 01, 2005 - In Conversation with…Peter J. Pronovost, MD, PhD
June 1, 2005
In Conversation with…Peter J. Pronovost, MD, PhD. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
Editor's Note: Peter J. Pronovost, MD, PhD, is Medical Director of the Johns Hopkins Center for
Innova…
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psnet.ahrq.gov/node/49697/psn-pdf
December 01, 2013 - Check the Anesthesia Machine
December 1, 2013
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/check-anesthesia-machine
The Case
A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension,
diabetes, sleep apnea…
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psnet.ahrq.gov/node/49387/psn-pdf
February 01, 2003 - Patient Mix-Up
February 1, 2003
Shojania KG. Patient Mix-Up. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/patient-mix
The Case
Joe Smith [not his real name], a 42-year-old man with nausea and vomiting for 4 days, was on the general
medical service at an academic medical center. Overnight, another man wit…
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psnet.ahrq.gov/node/33761/psn-pdf
February 01, 2014 - Interruptions and Distractions in Health Care: Improved
Safety With Mindfulness
February 1, 2014
Beyea SC. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness. PSNet
[internet]. 2014.
https://psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulne…
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_T2-Concise_Antibiogram_Toolkit_Getting_Started.doc
May 01, 2014 - Concise Antibiogram Toolkit
Getting Started—Sources of Data
2
Concise Antibiogram Toolkit
Getting Started—Sources of Data
Once you decide that an antibiogram will be a useful tool for your nursing home, there are a few things to consider.
1. What will you need to create the antibiogram?
2. What data are neede…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_3_Pres_video_508.pdf
June 02, 2025 - Strategy 3: Bedside Shift Report (Tool 3)
Guide to Patient & Family Engagement
Insert hospital logo here
Nurse Bedside
Shift Report Training
[Hospital Name | Presenter name and title | Date of presentation]
Strategy 3: Nurse Bedside Shift Report (Tool 3)
Today’s session
• What is patient and famil…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/beprepared_quickstartfull.pdf
January 01, 2015 - Implementation Quick Start Guide: Be Prepared to Be Engaged
Implementation
Quick Start Guide
Be Prepared
To Be Engaged
The Guide to Improving Patient Safety in Primary Care
Settings by Engaging Patients and Families
Table of Contents
What Is the Be Prepared To Be Engaged Strategy? .........................…
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www.ahrq.gov/teamstepps-program/curriculum/implement/pre/measure.html
January 01, 2024 - Measurement
Once the problem or challenge has been identified, measurement will play an important role in defining the magnitude of the problem, assessing the short-term reactions to the TeamSTEPPS training, and ultimately demonstrating improvements that follow TeamSTEPPS implementation.
Measurement is the pr…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/beprepared_quickstartbrochure.pdf
January 01, 2015 - Implementation Quick Start Guide: Be Prepared to Be Engaged (Half Page)
Implementation
Quick Start Guide
Be Prepared
To Be Engaged
The Guide to Improving Patient Safety
in Primary Care Settings by Engaging Patients
and Families
Table of Contents
What Is the Be Prepared To Be Engaged Strategy? ............…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/kit.html
June 01, 2017 - A Frontline Management System To Sustain Improvement in Safety Practices
Contents
1. Why a Frontline Management System?
2. Components of the Frontline Management System
3. Interactions of Components
4. Using the Model for Improvement
5. Additional Resources
1. Why a Frontline Management System?
M…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/strategies-slides.html
March 01, 2017 - Communication Strategies To Promote Resident Safety
AHRQ Safety Program for Long-Term Care: CAUTI
Slide 1: Communication Strategies To Promote Resident Safety
Slide 2: Objectives
After participating in the session, attendees will be able to—
I dentify possible barriers to effective communication w…
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digital.ahrq.gov/health-it-tools-and-resources/clinical-decision-support-cds
January 01, 2023 - Clinical Decision Support (CDS)
Below is an introduction to AHRQ’s CDS program and useful links to AHRQ CDS resources. What is CDS, and why is it important? CDS is a digital tool that provides timely information to help inform decisions about a patient's care, improve patient outcomes, and l…
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www.ahrq.gov/ncepcr/research-transform-primary-care/transform/impactgrants/impact-profile-ok.html
April 01, 2015 - Primary Care Extension in Oklahoma: An Evidence-Based Approach to Dissemination and Implementation of Innovations
AHRQ Estimating the Costs of Supporting Primary Care Transformation Grants
Principal Investigator: James W. Mold, MD, MPH
Institution: University of Oklahoma Health Sciences Center, …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/impact-profile-ok.pdf
April 01, 2015 - Primary Care Extension in Oklahoma: An Evidence-Based Approach to Dissemination and Implementation of Innovations
Primary Care Extension in Oklahoma: An Evidence-Based Approach to
Dissemination and Implementation of Innovations
Principal Investigator: James W. Mold, MD, MPH
Institution: University of …
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/interview-protocol-baseline-sw.pdf
April 04, 2016 - ENSW Baseline Semi-Structured Interview Guide
…