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4541. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mvp/ltvv-intro/ltvv-intro-facguide.docx
      January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle Slide Title and Commentary Slide Number and Slide Title Slide Low Tidal Volume Ventilation: Introduction, Evidence, and Implementation SAY: This module introduces and provides evidence for the lung protective low tidal volume strategy, and offers recommendation…

4542. Return on Investment Tool (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.pdf
      January 01, 2013 - Return on Investment Tool Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety i Tool F.1 Return on Investment Estimation What is the purpose of this tool? When your hospital invests in a new program, quality improvement intervention, or technology, leaders often need to kn…

4543. Return on Investment Estimation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/f1_pdi_returnoninvestment.pdf
      January 01, 2013 - Return on Investment Estimation Pediatric Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety i Tool F.1 Return on Investment Estimation What is the purpose of this tool? When your hospital invests in a new program, quality improvement intervention, or technology, leaders …

4544. Primary Care Practice Facilitation Curriculum Module 10: Mapping and Redesigning Workflow (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-10-workflow-mapping.pdf
      September 01, 2015 - Primary Care Practice Facilitation Curriculum Module 10: Mapping and Redesigning Workflow Primary Care Practice Facilitation Curriculum Module 10: Mapping and Redesigning Workfow Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov Primary Care Practice Facili…

4545. Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/OConnor.pdf
      November 29, 2004 - Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care 369 Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care Patrick J. O’Connor, JoAnn M. Sperl-Hillen, Paul E. Johnson, William A. Rush Abstract Objectives: Diabetes-related medic…

4546. An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Potter.pdf
      January 01, 2003 - An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors 39 An Analysis of Nurses’ Cognitive Work: A New Perspective for Understanding Medical Errors Patricia Potter, Laurie Wolf, Stuart Boxerman, Deborah Grayson, Jennifer Sledge, Clay Dunagan, Bradley Evanoff Abstract He…

4547. 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 - Medical Injury Identification Using Hospital Discharge Data 119 Medical Injury Identification Using Hospital Discharge Data Peter M. Layde, Linda N. Meurer, Clare Guse, John R. Meurer, Hongyan Yang, Prakash Laud, Evelyn M. Kuhn, Karen J. Brasel, Stephen W. Hargarten Abstract Objective: Determine the feasi…

4548. The CAHPS Ambulatory Care Improvement Guide: Are You Ready To Improve? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/3-are-you-ready/cahps-ambulatory-care-guide-section-3.pdf
      May 01, 2017 - The CAHPS Ambulatory Care Improvement Guide: Are You Ready To Improve? The CAHPS Ambulatory Care Improvement Guide Practical Strategies for Improving Patient Experience Section 3: Are You Ready To Improve? Visit the AHRQ Website for the full Guide. May 2017 (updated) https://www.ahrq.gov/cahps/quality-improve…

4549. Making Healthcare Safer Practices: 11. Patient Identification Errors in the Operating Room (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/patient-id-errors-1.pdf
      March 01, 2020 - Making Healthcare Safer Practices: 11. Patient Identification Errors in the Operating Room Patient Identification Errors in the Operating Room 11-1 11. Patient Identification Errors in the Operating Room Authors: Cori Sheedy, Ph.D., and Sonja Richard, M.P.H. Introduction In the first Making Health Care Safer …

4550. Usability Testing and the Relation of Clinical Information Systems to Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Rogers.pdf
      January 01, 2003 - Usability Testing and the Relation of Clinical Information Systems to Patient Safety 365 Usability Testing and the Relation of Clinical Information Systems to Patient Safety Michelle L. Rogers, Emily Patterson, Roger Chapman, Marta Render Abstract Background: The success of clinical information systems depend…

4551. Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Sirio.pdf
      June 15, 2003 - Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative 153 Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative Carl A. Sirio, Donna J. Keyser, Heidi Norman, Robert J. We…

4552. A Model-based Approach to Prioritizing Medical Safety Practices (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Marken.pdf
      January 01, 2004 - A Model-based Approach to Prioritizing Medical Safety Practices 409 A Model-based Approach to Prioritizing Medical Safety Practices Richard S. Marken Abstract This report shows how a model of skilled human performance can be used to evaluate safety practices aimed at reducing medical error when randomized tr…

4553. Beyond Nursing Quality Measurement: The Nation’s First Regional Nursing Virtual Dashboard (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Aydin_2.pdf
      January 01, 2021 - Beyond Nursing Quality Measurement: The Nation’s First Regional Nursing Virtual Dashboard rds Beyond Nursing Quality Measurement: The Nation’s First Regional Nursing Virtual Dashboard Carolyn E. Aydin, PhD; Linda Burnes Bolton, DrPH, RN, FAAN; Nancy Donaldson, DNSc, RN, FAAN; Diane Storer Brown, PhD, RN, FN…

4554. Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Hagg_80.pdf
      January 01, 2007 - Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption Heather Woodward Hagg, MS; Jamie Workman-Germann, MS; Mindy Flanagan, PhD; Deanna Suskovich, BA; Susan Schachitti, MBA; Christine Corum, MS; Bradley N. Do…

4555. Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Baker_107.pdf
      March 30, 2008 - Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems Donald K. Baker, PharmD; James M. Hoffman, PharmD; Gregory A. Hal…

4556. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
      April 02, 2008 - The Nature, Characteristics and Patterns of Perinatal Critical Events Teams The Nature, Characteristics and Patterns of Perinatal Critical Events Teams William Riley, PhD; Helen Hansen, PhD, RN; Ayse P. Gürses, PhD; Stanley Davis, MD; Kristi Miller, RN, MS; Reinhard Priester, JD Abstract The Institute …

4557. Error Producing Conditions in the Intensive Care Unit (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
      February 26, 2008 - Error Producing Conditions in the Intensive Care Unit Error Producing Conditions in the Intensive Care Unit Frank A. Drews, PhD; Adrian Musters, BS; Matthew H. Samore, MD Abstract Up to 98,000 patients die because of human error in U.S. hospitals each year. Among the areas where errors occur frequently is t…

4558. Chartbook on Black Health Care: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/qdr-blackhealth-slides.html
      November 01, 2020 - This marked the beginning of a new era in addressing minority health issues, beginning with the creation

4559. Network of Patient Safety Databases Chartbook, 2019 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
      January 01, 2019 - Safety and quality information has been collected by PSOs across many different settings, some addressing

4560. Final Progress Report: Risk-Informed Interventions in Community Pharmacy: Implementation and Evaluation (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/cohen2-report.pdf
      January 01, 2024 - Final Progress Report: Risk-Informed Interventions in Community Pharmacy: Implementation and Evaluation Final Report: Risk-Informed Interventions in Community Pharmacy: Implementation and Evaluation Principal Investigator: Michael R. Cohen, RPh, MS, ScD (hon), DPS (hon) Team Members: Judy L. Smetzer, RN, BSN,…