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psnet.ahrq.gov/issue/diagnostic-performance-medical-students-working-individually-or-teams
January 26, 2022 - Study
Diagnostic performance by medical students working individually or in teams.
Citation Text:
Hautz WE, Kämmer JE, Schauber SK, et al. Diagnostic performance by medical students working individually or in teams. JAMA. 2015;313(3):303-4. doi:10.1001/jama.2014.15770.
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psnet.ahrq.gov/issue/development-and-validation-tool-improve-paediatric-referralconsultation-communication
May 25, 2011 - Study
Development and validation of a tool to improve paediatric referral/consultation communication.
Citation Text:
Stille CJ, Mazor KM, Meterko V, et al. Development and validation of a tool to improve paediatric referral/consultation communication. BMJ Qual Saf. 2011;20(8):692-7. do…
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psnet.ahrq.gov/issue/health-information-technologies-hazardous-dark-side
January 24, 2024 - Commentary
Health information technologies: from hazardous to the dark side.
Citation Text:
Saunders C, Rutkowski AF, Pluyter J, et al. Health information technologies: From hazardous to the dark side. J Assoc Inf Sci Technol. 2016;67(7). doi:10.1002/asi.23671.
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psnet.ahrq.gov/issue/effect-safe-zone-nurse-interruptions-distractions-and-medication-administration-errors
October 19, 2022 - Study
The effect of a safe zone on nurse interruptions, distractions, and medication administration errors.
Citation Text:
Yoder M, Schadewald D, Dietrich K. The effect of a safe zone on nurse interruptions, distractions, and medication administration errors. J Infus Nurs. 2015;38(2):140…
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psnet.ahrq.gov/issue/errors-near-misses-and-adverse-events-emergency-department-what-can-patients-tell-us
April 25, 2018 - Study
Errors, near misses and adverse events in the emergency department: what can patients tell us?
Citation Text:
Friedman SM, Provan D, Moore S, et al. Errors, near misses and adverse events in the emergency department: what can patients tell us? CJEM. 2008;10(5):421-427.
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psnet.ahrq.gov/issue/swapping-horses-midstream-factors-related-physicians-changing-their-minds-about-diagnosis
January 29, 2020 - Study
Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis.
Citation Text:
Eva KW, Link CL, Lutfey KE, et al. Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis. Acad Med. 2010;85(7):1112-7. doi:10.…
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integrationacademy.ahrq.gov/sites/default/files/2025-06/Innovations%20in%20Behavioral%20Health%20Integration_Transcript.docx
January 01, 2025 - We had the care managers trained up to be able to coordinate care for both those disorders, including
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www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
December 01, 2017 - If a task requires two people, two trained people should be assigned to complete the task.
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digital.ahrq.gov/sites/default/files/docs/citation/r18hs025654-lenert_final-report-2023.pdf.pdf
January 01, 2023 - We tested the navigator tools for provider assessment and management of IPV risk using trained
standardized
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Fein.pdf
January 01, 2004 - A Conceptual Model for Disclosure of Medical Errors
483
A Conceptual Model for
Disclosure of Medical Errors
Stephanie Fein, Lee Hilborne, Margie Kagawa-Singer, Eugene Spiritus,
Craig Keenan, Gregory Seymann, Kaveh Sojania, Neil Wenger
Abstract
Objective: Patient safety is fundamental to high-quality patient…
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-10-implementation-guide.pdf
April 16, 2022 - 1
TAKEheart Hybrid Cardiac Rehabilitaton {CR) Implementation Guide - Module 10
Using Hybrid Cardiac Rehabilitation to Expand System Capacity and
Patient-Centeredness
Table of Contents
This document is hyperlinked to facilitate ease of access to the information contained inside.
Press "ctrl" and …
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight09.pdf
September 08, 2015 - How are CHIPRA quality demonstration States supporting the use of care coordinators? Evaluation Highlight No. 9
The CHIPRA Quality
Demonstration Grant Program
In February 2010, the Centers for Medicare &
Medicaid Services (CMS) awarded 10 grants,
funding 18 States, to improve the quality of
health care for chil…
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psnet.ahrq.gov/node/49409/psn-pdf
July 01, 2003 - Feeling No Pain
July 1, 2003
Bogner MS. Feeling No Pain. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/feeling-no-pain
The Case
A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the
patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
February 01, 2014 - PowerPoint Presentation
Spotlight Case
Multifactorial Medication Mishap
1
This presentation is based on the February 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Annie Yang, PharmD, BCPS
NYU Langone Medical Center
Editor, AHRQ WebM&M: Robe…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/safetransitions/safetransitions.pptx
June 02, 2025 - Slide Presentation: An Introduction to Safe Transitions for Patients to New Appointments
An Introduction to Safe Transitions for Patients to New Appointments
Ambulatory Care Facility
Team Presentation
Overview
Purpose and Benefits
Toolkit Components
Team Member Roles and Responsibilities
Implementation Steps
Resourc…
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www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/best-practices-managing-deconditioning.pdf
May 01, 2022 - Best Practices for Identifying and Managing Deconditioning in Nursing Home Residents
Best Practices for Identifying and Managing
Deconditioning in Nursing Home Residents
Throughout the COVID-19 pandemic, many nursing home residents had less physical and social activity
than recommended, resulting in d…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-ASC-webcast-2023-0509-hare.pdf
January 01, 2023 - SOPS Ambulatory Surgery Center Webcast - HARE
SOPS ASC Survey, Database and Resources
Ryan Hare, MPP
Lead Research Associate
User Network for the AHRQ Surveys on Patient Safety Culture (SOPS)
Westat
13
SOPS ASC Survey
• Designed specifically for ASC staff and asks for their opinions
about the culture of patie…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-team-slides.pptx
April 01, 2022 - Building an Engaged CUSP Team Slides
Building an Engaged Comprehensive Unit-based Safety Program Team
AHRQ Safety Program for Intensive Care Units:
Preventing CLABSI and CAUTI
AHRQ Pub. No. 17(22)-0019
April 2022
1
Objectives
Identify tools and resources available to support your CLABSI and/or CAUTI improvemen…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/visual-fac-notes.html
June 01, 2017 - Module 5: Visual Management - Facilitator Notes
Slide 1: Management Practices for Sustainability Module 5: Visual Management
Say:
As mentioned in the module on huddles, the frontline management system used to promote sustained, controlled standard work that ensures patient safety relies on several interlo…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-maintenance.pptx
April 01, 2022 - Central Venous Catheter Maintenance
Central Venous Catheter Maintenance
Maintaining Awareness and Proper Care of Catheters in Place
AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI
AHRQ Pub. No. 17(22)-0019
April 2022
1
Step 2. Maintenance
Disrupting the Life Cycle of a Catheter Device1…