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441. AHRQ Safety Program for Perinatal Care: Safe Medication Administration: Oxytocin (doc file)
     patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/tool_safe-oxytocin.docx
     May 01, 2017 - the unit learn from defects and sensemaking using the following tools: · Discovery form · Root cause analysis … · Eindhoven model · Failure mode and effects analysis · Probabilistic risk assessment · Causal tree … Share outcomes or process improvements from the informal (debriefing) and formal analysis with staff

442. TeamSTEPPS Module 1: Introduction (Instructor Guide) (pdf file)
     patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module1/igintro-cx062819.pdf
     January 01, 2007 - This case study analysis included formative and summative research methods looking at strengths, weaknesses … For example, a meta-analysis published in 2008 (Salas, et al., 2008) included a comprehensive search … Although this meta-analysis was not specific to team training in health care, its results demonstrated

443. Module 5: How To Measure Fall Rates and Fall Prevention Practices—Training Guide | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/guide.html
     September 01, 2017 - This is the level of fall injury where it is recommended that you perform a root cause analysis to find … Refer to page 76 of the Toolkit for additional resources regarding root cause analysis and huddles. … Do: Suggest that those who are doing the data collection and analysis view the following webinars for

444. Improving Health Information Technology (IT) Patient Safety: A Resource List for Users of the AHRQ Health Information Technology Supplemental Item Set (pdf file)
     patientregistry.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/patient-safety-technology-resources.pdf
     May 01, 2023 - The path to successful EHR implementation starts with practice workflow analysis and redesign. … associated with the most severe consequences—although ECRI does consider such information in their analysis

445. Study Finds Racial and Ethnic Inequities in End-of-Life Prescription Opioid Access | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/news/newsletters/e-newsletter/875.html
     August 01, 2023 - Hospitalization due to adverse drug events in older adults with cancer: a retrospective analysis .

446. Issue Brief Explores the Unique Challenges of Studying and Improving Diagnostic Safety for Children | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/news/newsletters/e-newsletter/879.html
     September 01, 2023 - Diagnostic reliability in teledermatology: a systematic review and a meta-analysis .

447. AHRQ Views Blog Post: With TeamSTEPPS 3.0, AHRQ Refreshes a Landmark Patient Safety Training Curriculum | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/news/newsletters/e-newsletter/880.html
     September 01, 2023 - Sensitivity analysis using bias functions for studies extending inferences from a randomized trial to

448. Resource List - AHRQ Medical Office Survey (pdf file)
     patientregistry.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medoffice-resourcelist.pdf
     April 01, 2023 - Root Cause Analysis a. … Department of Veterans Affairs National Center for Patient Safety –Root Cause Analysis http://www.patientsafety.va.gov … The National Center for Patient Safety uses a multidisciplinary team approach, known as root cause analysis … Safety Program Toolkits Department of Veterans Affairs National Center for Patient Safety –Root Cause Analysis … Root Cause Analysis 2. Plan-Do-Study-Act (PDSA) Steps and Worksheet 3.

449. Communication Assessment Guide | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5.html
     August 01, 2022 - Then score as described below, and enter the scores into the spreadsheet for further analysis.

450. Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles: Facilitator Notes | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-facguide.html
     March 01, 2017 - Sigma Institute for Healthcare Improvement's Model for Improvement Plan-Do-Study-Act Root Cause Analysis … Failure Mode Effect Analysis In addition to these tools, a number of LTC-specific resources offer

451. Module 4: How to Implement the Fall Prevention Program in Your Organization (doc file)
     patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module4/module4_fall-prevention.docx
     September 20, 2017 - of rolling out new practices tends to be most successful when teams follow a systematic approach to analysis … including didactic methods such as lectures, interactive presentations, online lessons, case-study analysis

452. SOPS® Value and Efficiency Supplemental Items for the SOPS Hospital Survey - Spanish (doc file)
     patientregistry.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/spanish-hospital-ve-supp-item-set-2022.docx
     January 01, 2022 - Additionally, the Data Entry and Analysis Tool for the Value and Efficiency Supplemental Item Set for

453. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/hai/pfp/2014-final.html
     January 01, 2018 - We directly estimate the size of the reduction in HAC rates but rely on analysis from other researchers … The estimates used in our analysis originate from a variety of sources and methodologies.

454. Ingestion of Illicit Substances Among Young Children Increased Significantly During COVID-19 Pandemic | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/news/newsletters/e-newsletter/861.html
     April 01, 2023 - administration in patients with acute kidney injury: a multi-site retrospective propensity-adjusted analysis

455. AHRQ Views Blog: Long COVID Is a Case Study of Our Fractured Healthcare System | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/news/newsletters/e-newsletter/856.html
     March 01, 2023 - capture of intraoperative adverse events using artificial intelligence: a systematic review and meta-analysis

456. Study Finds Patients Who Self-Test Negative for COVID-19 Not Properly Quarantining | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/news/newsletters/e-newsletter/821.html
     June 01, 2022 - Analysis of Hospital-Level Readmission Rates and Variation in Adverse Events Among Patients With Pneumonia

457. AHRQ Views: For Women’s Health Week, Let’s Make Prevention Primary | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/news/newsletters/e-newsletter/864.html
     May 01, 2023 - Factors contributing to preventing operating room "never events": a machine learning analysis .

458. AHRQ Releases Annual Update on U.S. Healthcare Quality, Equity | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/news/newsletters/e-newsletter/839.html
     November 01, 2022 - between care fragmentation and total spending after durable left ventricular device implant: A mediation analysis

459. Special Edition – Patient Safety Awareness Week | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/news/newsletters/e-newsletter/854.html
     March 01, 2023 - which address topics such as communication improvement, education and training, and error reporting and analysis

460. AHRQ Views Blog: Unveiling a Research Agenda To Transform Care for People With Multiple Chronic Conditions | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/news/newsletters/e-newsletter/787.html
     November 01, 2021 - This research, based on an analysis of data from 2015-2019, concludes that families making more than