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421. Using Lean Six Sigma® Tools to Compare INR Measurements from Different Laboratories Within a Community (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Hurley_55.pdf
     March 07, 2008 - service area of around 300,000.2 Warfarin anticoagulation accounts for approximately 25 percent of adverse … drug events (ADEs)3 (i.e., any unexpected or dangerous reaction to a drug) in the two community hospitals … of such a clinic would also improve the culture of safety within the community, reduce errors and adverse … drug reactions, and reduce readmissions for complications in patients taking warfarin. 1 Establishing … drug events), shorter response times in communicating results to the patient, better patient access

422. Final Progress Report: Advancing Patient Safety Implementation through Pharmacy-Based Opioid Medication Use Research (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/green-report.pdf
     January 01, 2024 - Nature of preventable adverse drug events in hospitals:A literature review.

423. IV. Evaluation Aims, Methods, and Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/eval4.html
     May 01, 2016 - Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events IV. Evaluation Aims, Methods, and Results Previous Page Next Page Table of Contents Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for …

424. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-031121.pdf
     July 22, 2021 - Federal Interagency Workgroup on Improving Diagnostic Safety and Quality 1 Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care Workgroup Goal: Established by Senate Report 115-150. The Senate Committee on Appropriations requested “AHRQ to convene a cross agency working group t…

425. Library of PCOR Resources | Agency for Healthcare Research and Quality
     www.ahrq.gov/pcor/library-of-resources/index.html
     April 01, 2021 - Library of PCOR Resources The Agency for Healthcare Research and Quality (AHRQ) provides this comprehensive Web library of patient-centered outcomes research (PCOR) resources to highlight the existing collection of PCOR projects conducted by public, private, nonprofit, and academic sources. The library of resou…

426. Final Progress Report: Quality Care and Error Reduction in Rural Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/cook-hoas-report.pdf
     January 01, 2024 - Final Progress Report: Quality Care and Error Reduction in Rural Hospitals Principal Investigator: Cook, Ann F. Title of the Project: Quality Care and Error Reduction in Rural Hospitals Principal Investigator: Ann Cook, Ph.D. Co-investigator: Helena Hoas, Ph.D. Team Member: Katarina Guttmannova, Ph.D. Organizat…

427. Regulation of Health Policy: Patient Safety and the States (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weinberg.pdf
     March 01, 2004 - Regulation of Health Policy: Patient Safety and the States 405 Regulation of Health Policy: Patient Safety and the States Joanna Weinberg, Lee H. Hilborne, Quang-Tuyen Nguyen Abstract In its 1999 report on patient safety, the Institute of Medicine recommended a nationwide mandatory reporting system to co…

428. Improving the Safety and Quality of Health Care: The Impact of the National Academy of Medicine on Research and Collaboration (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/dzau-summit2016.pdf
     September 28, 2016 - reduction in HACs and that approximately $19.8 billion in health care costs were saved from 2010 to 2014 Adverse … Drug Events Pressure Ulcers Catheter Associated Urinary Tract Infections Surgical Site

429. Minding the Gaps: Creating Resilience in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Nemeth_116.pdf
     April 27, 2008 - Minding the Gaps: Creating Resilience in Health Care Minding the Gaps: Creating Resilience in Health Care Christopher Nemeth, PhD; Robert Wears, MD; David Woods, PhD; Erik Hollnagel, PhD; Richard Cook, MD Abstract Resilience is the intrinsic ability of a system to adjust its functioning prior to, during, or …

430. AHRQ Safety Program for MRSA Prevention
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/008-antibiotic-stewardship-slides.pptx
     October 01, 2022 - AHRQ Safety Program for MRSA Prevention AHRQ Safety Program for MRSA Prevention Antibiotic Stewardship and MRSA Reduction ICU & Non-ICU AHRQ Pub. No. 25-0007 October 2024 AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU Antibiotic Stewardship 1 Educational Objectives Understand the goals of antibiotic ste…

431. Final Progress Report: Four Safety Strategies: A Symposium on Implementation (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/pittman-report.pdf
     January 01, 2024 - Healthcare Improvement and has co-chaired two Institute for Healthcare Improvement Collaboratives on adverse … drug events.

432. Behavioral Health AI Free Text Analysis - NPSD Data Spotlight (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/npsd-spotlight_behavioral-health.pdf
     September 01, 2025 - Behavioral Health AI Free Text Analysis - NPSD Data Spotlight NPSD Data Spotlight: Behavioral Health AI Free-Text Analysis Behavioral Health AI Free Text Analysis Page | i This document is in the public domain and may be used and reprinted with…

433. Work System Analysis: The Key to Understanding Health Care Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
     April 22, 2004 - The system analysis uncovered new side effects of the technology, including unanticipated routes to adverse … drug events. … Systems analysis of adverse drug events. JAMA 1995 Jul 5;274(1):35–43. 15. Nolan T.

434. Final Progress Report: Weekend Effects and the July Phenomenon in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/weissman-report.pdf
     January 01, 2024 - Final Progress Report: Weekend Effects and the July Phenomenon in Patient Safety --------------------------------------- Weekend Effects and the July Phenomenon in Patient Safety Final Research Report to AHRQ Principal Investigator: Joel S. Weissman, PhD February 6, 2006 Co-Investigators and Study Staff (i…

435. Partnering-Executive-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/partnering-executive-facilitator-guide.docx
     June 01, 2021 - team members, instead of demanding things from reluctant staff · Quantify and report reductions in adverse … drug events or Clostridioides difficile rates · Gain many other potential benefits that can lead to

436. Antibiotic-Patient-Safety-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-patient-safety-facilitator-guide.docx
     June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use 1 Improving Antibiotic Use Is a Patient Safety Issue Long-Term Care Slide Title and Commentary Slide Number and Slide Improving Antibiotic Use Is a Patient Safety Issue Long-Term Care SAY: Welcome to this presentation titled “Improving Antibiotic Use Is a Patie…

437. Meeting Minutes, March 2018 | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/events/nac/2018-03-nac/nacmtg0317-minutes.html
     July 01, 2018 - For example, rates of HACs related to adverse drug events have been falling for the past 5 years.

438. 003-Ss-Antimicrobial-Prophylaxis-Part-2-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/003-ss-antimicrobial-prophylaxis-part-2-fg.docx
     April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI Antimicrobial Prophylaxis: Part 2 Beyond the Basics Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries Slide Title and Commentary Slide Number and Slide Antimicrobial Prophylaxis: Part 2, Beyond the Basics SAY: This pr…

439. Slide 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/briefing-slides/Morning-Briefing-and-Shadowing-July-12-2011-508.ppt
     January 01, 2011 - Slide 1 On the CUSP: STOP BSI Improving Situational Awareness by Conducting a Morning Briefing Situation Awareness -- An Overview Members of the team have an understanding of what’s going on and what is likely to happen next Teams are alert to developing situations, sensitive to cues, and aware of their impli…

440. Chapter 6. Track Performance with Metrics | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide6.html
     May 01, 2016 - having significant drops in hemoglobin while on anticoagulation can spur chart review to determine if an adverse … drug event occurred, to assess the level of harm, and to examine the case for error. 20 An approach … reviewed for a list of "triggers" for further review. 21 Triggers potentially related to anticoagulant adverse … drug events (ADEs), such as an elevated INR, elevated PTT, use of anticoagulant reversal agents, change