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1. Cusp Patient Family Engagement Facilitator Notes (doc file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
   June 02, 2025 - Slide 1 SAY: In this module we will: · Explore the role of patient and family advisors in ensuring … Clinicians bring clinical judgment to the table, and while this is important, it is not the only perspective … Providers must document in the medical record the facts of the incident and any care the patient received … event, and the care provided as a result of the event. … It should track, trend, and analyze necessary data for quality assurance and other identified purposes

2. Serious Reportable Adverse Events in Health Care (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer2.pdf
   December 01, 2000 - care.3 For purposes of this project, public accountability was considered to be the obligation or … provided by the health care facility Includes generally detectable contaminants in drugs, devices … ICD codes serve as tools for classifying morbidity data for medical records indexing, medical care review … If this is not done, States should, at a minimum, enact policies that allow the same data in the same … ) have a reciprocal obligation to ensure that the data provided by the reports are available to the

3. Final Progress Report: Evaluate the Effects of the Massachusetts Reporting System (pdf file)
   www.ahrq.gov/sites/default/files/2024-11/ridley-report.pdf
   January 01, 2024 - Data were abstracted from records of these hospital reported incidents in both summary electronic form … The hospital’s medical records department then either 1) provided the research team with a file from … In order to do this, they took each sample list of discharges provided by hospitals; after cleaning … A summary of the patient self-reported AE was provided in the data tool. … This sample is close to the original 4200 sample predicted in the research plan.

4. Patient and Family Engagement | Agency for Healthcare Research and Quality
   www.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
   September 01, 2013 - The CUSP toolkit is a modular approach to patient safety, and modules presented in this toolkit are interconnected … Clinicians bring clinical judgment to the table, and while this is important, it is not the only perspective … Providers must document in the medical record the facts of the incident and any intervention the patient … event, and the care provided as a result of the event … It should track, trend, and analyze necessary data for quality assurance and other identified purposes

5. Medical Injury Identification Using Hospital Discharge Data (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Layde.pdf
   January 01, 2003 - Newborn delivery discharges were excluded for the purposes of this analysis. … A more detailed categorization of the nature of the medical injuries is provided by the 40 subcategories … that for identifying injury caused by health care interventions.2, 6 The criteria evaluated in this … Because it is based on hospital discharge data collected for administrative purposes, this approach … While medical record review is regarded as the gold standard in patient safety studies, there is evidence

6. Final progress report: Developing Evidence for Safety Surveillance from Device Adverse Event Reports (pdf file)
   www.ahrq.gov/sites/default/files/2025-02/mao-report.pdf
   January 01, 2025 - by the FDA.1 Our previous studies using administrative data in the US found that the risk of reoperation … For this reason, research with population-level data, such as claims and administrative databases, are … The MAUDE database is a reporting system mandated by the FDA for postmarket device surveillance. … as well as reports submitted by voluntary reporters.4 It is a publicly available data source. … For the development of the NLP model, gold standard documents by human annotation must be provided as

7. Education in Proper Use of New Asthma Medication Delivery Device for Children With Asthma (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-201-fullreport.pdf
   March 01, 2019 - For the purposes of this measure, education in proper use is defined as documentation of verbal instruction … Yes; this measure requires medical record abstraction; medical records are maintained by all health … This measure requires medical record abstraction; medical records are maintained by all health services … For the purposes of this measure, education in proper use is defined as verbal instruction, education … of regularly implementing this measure with data supplied by electronic medical records.

8. Envisioning Patient Safety in the Year 2025: Eight Perspectives (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Henriksen_104.pdf
   January 01, 2025 - Changing this system is the ultimate political challenge. … to the patient’s personal health record. … enhanced this oversight, streamlined problem reporting databases, and facilitated data mining and analysis … amplify them, or to replace them for the appropriate purposes. … This dominance of safety work by socially powerful groups within a field of practice is strikingly different

9. Readmissions for Selected Infections Due to Medical Care: Expanding the Definition of a Patient Safety Indicator (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Gallagher2.pdf
   January 01, 2016 - is responsible for overseeing the data and ensuring the accuracy of the information. … appendix cited in this report is available from the corresponding author. … This is appropriate in New York SPARCS, where the medical record number for the same patient is maintained … This second criteria allowed for the linkage of records for a single individual across hospitals. … This task is critical in the all-important quest to optimize the safety and quality of health care in

10. Appendix B1: The FMP Self-Assessment Tool (Text Description) | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb1txt.html
    December 01, 2017 - Further instructions are provided in the Chart Audit section. … For accuracy, use only the information that is written in the chart and care plan. … All areas warrant assessment and should be accessible in the medical record. … Data collected after each fall? (If fall is unwitnessed, give credit for investigation.) … For those areas with a No , put a check by it in the list below.

11. The Impact of Personal Digital Assistant Devices on Medication Safety in Primary Care (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Galt.pdf
    January 01, 2005 - By studying this voluntary adoption, we improve our accuracy in projecting what the impact of PDA prescribing … The Centers for Medicare and Medicaid Services has made the adoption of electronic medical records and … This study is not designed to detect variations in medication errors that may be caused by characteristics … Acknowledgments This study was supported in part by Grant Number R18HS11808-1, Agency for Healthcare … The need for obligatory printing in medical records (letter). Hosp. Pharm1991;26:924. 11.

12. The Role of Patient Safety in the Device Purchasing Process (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Johnson.pdf
    January 01, 2004 - The latter two aspects of the framework provided additional evidence for evaluating the quality of the … data, question-by-question, in an effort to develop an overall picture of the purchase process for … to additional pumps very early in the process, but this is not reflected in the meeting minutes. … The limitations identified in this study do not reflect a lack of concern for patient safety among the … It also calls into question the methods by which device usage is used to generate feedback for the

13. National Opportunity To Improve Infection Control in ESRD (NOTICE) Phase Two Final Report (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/finalreportphase2.pdf
    September 29, 2014 - Data Sources CMS Claims The UM-KECC ESRD Database includes administrative and billing records for … A feature of the study is that almost all of the data collected is by self-report of the dialysis facilities … This refined version is currently in use by State surveyors. … • Record date and shift for every observation. … agreement that commits them to only using this data for the purposes described above.

14. Developing a Veterans Health Administration (VHA) Serious Injury Surveillance System that Includes Adverse Event Hospitalizations (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Campbell.pdf
    January 01, 2003 - Center for Patient Safety is a leader in this movement. … STIPDA also noted “hospital discharge data may be more useful than vital records for surveillance in … use of hospital discharge data for injury surveillance purposes. … The DSS cost data of VHA provided average cost data by CCS injury categories for the analyses. … Second, hospital discharge data is primarily collected for billing purposes and not to conduct injury

15. Final Progress Report: Improving Medication Safety Across Clinical Settings (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/bates-report.pdf
    January 01, 2024 - purposes. … in the medical record. … Modules can be programmed to record data associated with IV drug infusion either with the feedback … For the purpose of this study, a PAWE is defined as an INR level above 4.5.) 3. … records by trained nurse abstractors.

16. NPSD Data Spotlight - Falls: Associated Factors and Clinical Outcomes (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-falls-rev.pdf
    March 01, 2023 - Clinical Outcomes NPSD Data Spotlight This document is in the public domain and may be used and … For statistical purposes and ease of visualization across age groups, reports across the Neonate (0- … Text was provided for 20.9% of Female patients (366 / 1,753 records) compared to 18.6% of Male patients … Text descriptions were more commonly provided for Older adults aged 75-84 (39.1 %; 790 / 2,022 records … Text was more commonly provided for Female patients (36.8%; 2,540 / 6,911 records) than Male patients

17. Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_38.pdf
    March 26, 2008 - , and an internet computer-based training module provided by the vendor. … The monitors provided PCA/EtCO2 and PCA/SpO2 trending data at the bedside to assist clinicians in assessing … This value is the number of instances for which there are documented case reports. … In some cases, capnographic data provided the only indication of respiratory depression.11 9 … For this reason, the use of respiratory monitoring, especially capnometry, is important for patients

18. Final Progress Report: Safety in the Home Healthcare Sector: A Pilot Study (pdf file)
    www.ahrq.gov/sites/default/files/2024-11/gershon-report.pdf
    January 01, 2024 - safety records for HROs.10 The five basic tenets of systems-level safety adopted by the HROs are as follows … Even with increasing acuteness of care that is provided in the home setting, the cost of HHC is significantly … needed by 2030.26 This is especially problematic given that the workforce itself is undergoing similar … Last, limited safety training is generally provided, especially by some of the smaller agencies. … the aides, for follow-up purposes.

19. Labor and Delivery Unit Safety: Safe Cesarean Section | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-safe-csection.html
    July 01, 2023 - An example of a safe cesarean section checklist is provided in the Appendix of this tool. … The timeout is typically led by the circulating nurse once all staff members are present in the operating … Sample safe cesarean section checklists are provided in the Appendix of this tool. … Is taken seriously by the surgical team, as opposed to viewing the process as an exercise in documentation … timing and location as shown in the following figure: This sample tool is based on the framework

20. Final Progress Report: Developing and Training Interruption Management Strategies for Emergency Physicians (pdf file)
    www.ahrq.gov/sites/default/files/2024-09/ratwani-report.pdf
    January 01, 2024 - Figure 1 shows the web-based application that was used for data collection. … resident in order to keep the primary task goal in memory if it is safe to do this. 7 Strategy … High-Priority Primary Task/High-Priority Interrupting Task: A 45-year-old man is brought in by EMS for … where to find the special instructions in the electronic health record for medication orders. … in the electronic health record for a patient who presented to the ED with minor bruises from a fall