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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - May 27, 2010
Doing the "right" things to correct wrong-site surgery.
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psnet.ahrq.gov/web-mm/techno-trip
May 01, 2005 - this one demonstrate that IT in health care requires more than simply adding "computerization" to make things
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/back-pain-treatment_consumer.pdf
November 01, 2016 - Here are some things to think about.
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs021681-zikmund-fisher-final-report-2017.pdf
January 01, 2017 - significantly increasing negative perceptions (a concern since red might have
been seen as implying negative things
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psnet.ahrq.gov/web-mm/carpe-diem-seize-day
September 01, 2012 - Carpe Diem (Seize the Day)
Citation Text:
Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/specimen-almost-lost
September 21, 2022 - Specimen Almost Lost
Citation Text:
Hehe YK. Specimen Almost Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - Spotlight
Too Many Cooks in the Kitchen
Source and Credits
• This presentation is based on the August 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Richard P. Dutton, MD, MBA
o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…
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psnet.ahrq.gov/node/49493/psn-pdf
November 01, 2005 - Infused, Not Ingested
November 1, 2005
Foley M. Infused, Not Ingested. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/infused-not-ingested
The Case
A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering
contrast, an unfamiliar task for this particular nurse. Rathe…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/physician-staff-engagement-slides.pptx
January 01, 2017 - Presentation: Program Overview
Physician and Staff Engagement
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-32-EF
January 2017
Physician and Staff Engagement ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
1
Learning Objectives
After this session, you will b…
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www.ahrq.gov/hai/tools/mvp/modules/vae/surveillance-fac-guide.html
February 01, 2017 - Ventilator-Associated Event Surveillance: Facilitator Guide
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: Ventilator-Associated Event Surveillance
Say:
This module will focus on ventilator-associated event surveillance and how it can be used in your unit.
Slide 2: Learning Objectiv…
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www.ahrq.gov/hai/tools/mvp/modules/cusp/assess-psc-hsop-slides.html
February 01, 2017 - Assess Patient Safety Culture Using the Hospital Survey on Patient Safety: Slide Presentation
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients
Assess Patient Safety Culture Using the Hospital Survey on Patient Safety
Slide 2: Lear…
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/workforce-turnover-crisis.pdf
April 01, 2025 - Slide Presentation - Workforce Safety and Well-Being Webinar Series (Session 3): Resolving Workforce Turnover Crisis
Workforce Safety and Well-being Webinar Series (Session 3)
Resolving The Workforce Turnover Crisis
NATIONAL WEBINAR SERIES
December 10, 2024
Housekeeping Instructions
• This webinar will be recor…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-203-section-6-b-workgroup.pdf
September 18, 2014 - PMCoE PICU Expert Work Group and Leadership Team Roster
…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-199-section-6-b-pmcoe-picu-expert-workgroup.pdf
September 18, 2014 - Section 6-B, PMCoE PICU Expert Workgroup and Leadership Team Roster
…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-200-section-6-b-expert-workgroup.pdf
September 18, 2014 - Section 6-B, Expert Workgroup Roster and Materials
…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4c_pdi03-foreignbody-bestpractices.pdf
November 01, 2012 - Selected Best Practices and Suggestions for Improvement
Pediatric Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4c
Selected Best Practices and Suggestions for Improvement
PDI 03: Retained Surgical Item or Unretrieved Device Fragment Count
Why focus on reta…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/nh-workplace-safety-yount.pdf
January 01, 2023 - New AHRQ SOPS® Workplace Safety Supplemental Item Set for Nursing Homes - Naomi Yount, PhD
Workplace Safety Supplemental Item Set
for the SOPS Nursing Home Survey
Naomi Yount, PhD
Senior Study Director
Westat
31
Workplace Safety Supplemental Item Set
• Designed as a supplemental item set that can be added towa…
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - Patient Safety 101
Citation Text:
Patient Safety 101. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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D…
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digital.ahrq.gov/ahrq-funded-projects/evaluating-impact-acpoecds-system-outcomes
January 01, 2023 - Evaluating the Impact of an ACPOE/CDS System on Outcomes
Project Final Report ( PDF , 806.9 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHR…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4q_combo_pdi03-foreignbody-bestpractices.pdf
November 01, 2012 - Selected Best Practices and Suggestions for Improvement
Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4q
Selected Best Practices and Suggestions for Improvement
PDI 03: Retained Surgical Item or Unretrieved Device Fragment Count
Why focus on retained forei…