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121. Planning Grants Final Evaluation Report: Longitudinal Evaluation of the PSML Reform Demonstration Program (pdf file)
     talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
     May 01, 2016 - A separate analysis of patient complaints indicated that 78% involved an element of informed consent … Themes and subthemes emerging from the analysis suggest failures may occur in multiple domains of the … Including nurses and other clinical staff in the formal root cause analysis (a common error analysis … of medical claims closed over an 11-year period; a retrospective analysis of selected closed claim … During this time period, 41 claims had sufficient data for analysis.

122. Snapshot of U.S. Health Systems, 2016 (pdf file)
     talkingquality.ahrq.gov/sites/default/files/wysiwyg/chsp/data/chsp-brief1-snapshot-of-us-health-systems-2016.pdf
     January 01, 2016 - Agency for Healthcare Research and Quality *This analysis is based on AHRQ’s Compendium of U.S. … ++ More than half of health systems have fewer than 250 total physicians. 3 Methods This analysis … the three data sources and systems’ members specified in the data, systems may be included in this analysis … These cases were updated as they were identified throughout the analysis.

123. Variation in Health System Characteristics Across States, 2016 (pdf file)
     talkingquality.ahrq.gov/sites/default/files/wysiwyg/chsp/data/chsp-brief2-us-health-system-characteristics-2016.pdf
     January 01, 2016 - Health System Characteristics, 2016 *This analysis is based on AHRQ’s Compendium of U.S. … chsp-reports/resources-for-understanding-health-systems/defining-health-systems.html 2 METHODS This analysis … the three data sources and systems’ members specified in the data, systems may be included in this analysis … These cases were updated as they were identified throughout the analysis.

124. Toolkit for Using the AHRQ Quality Indicators | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/patient-safety/settings/hospital/resource/qitool/index.html
     March 01, 2017 - Includes: 25 indicator-specific best practices, a project charter, a gap analysis, and an implementation … Instructions; PowerPoint Presentation: The AHRQ Quality Indicators, Results, and Discussion of Data Analysis … Indicator Rates Using Trends and Comparators Includes guidance for conducting trend and comparator analysis … Gap Analysis Includes a tool to help you understand how your organization's practices align with best

125. TeamSTEPPS 2.0 Evidence Base: Situation Monitoring (pdf file)
     talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module5/ebsitmonitor.pdf
     January 01, 2013 - Situation awareness analysis and measurement. … The cognitive underpinnings of effective teamwork: a meta- analysis. … Metacognition research and theory: Analysis and implications for instructional design.

126. Mod4-Event-Checklist (pdf file)
     talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-event-checklist.pdf
     April 01, 2016 - Event Investigation and Analysis Steps for Investigation and Analysis ■ Identify any potential issues

127. Food Assistance Linked to Improved Health and Reduced Emergency Care Among Low-Income Children | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/news/newsletters/e-newsletter/853.html
     March 01, 2023 - Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis … An analysis of prehospital pediatric medication dosing errors after implementation of a state-wide EMS … Interventions to improve outcomes for high-need, high-cost patients: a systematic review and meta-analysis

128. Biden Administration Tackles Financial Strains on Healthcare Consumers | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/news/blog/ahrqviews/financial-strains-healthcare.html
     November 01, 2023 - Therefore, it is not surprising that our analysis finds widespread financial strain associated with healthcare … Our analysis of the joint distribution of financial burden, medical debt, and financial barriers to needed

129. At the American Society of Health Economists Conference, AHRQ to Highlight Its Deep Dive into COVID-19 | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/news/blog/ahrqviews/deep-dive-into-covid19.html
     June 01, 2023 - Lan Liang, Ph.D., will present an HCUP-based analysis of COVID-19’s impact on racial and ethnic differences … Other MEPS-based presentations include an analysis by Giacomo Meille, Ph.D., and Jessica Monnet Ph.D.

130. Best Practices in Fall Prevention
     talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_slides_best-practices.pptx
     June 16, 2017 - factors Care planning and interventions that address risk factors within an overall patient care plan Analysis … predicted before the first occurrence Unanticipated Physiological Fall Unpreventable Falls ‹#› 43 Analysis … Analysis of the data collection may help prevent the next fall in this patient or future patients. … The analysis captures information from the patient, staff, and other witnesses about the fall. … Refer to Tool 3O: Post-Fall Assessment for Root Cause Analysis. ‹#› 46 Incorporate Best Practices

131. Well-Child Visits on the Rise, But Disturbing Gaps Remain for Underserved Populations | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/news/newsletters/e-newsletter/828.html
     August 01, 2022 - but large gaps remain across race/ethnicity, poverty level, insurance and geography, a new AHRQ data analysis … AHRQ in the Professional Literature A disproportionality analysis of drug-drug interactions of tizanidine … survival in older nursing home residents with advanced non-small-cell lung cancer: a SEER-Medicare analysis

132. AHRQ’s Measure Dx Tool: Discover and Learn From Diagnostic Errors | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/news/newsletters/e-newsletter/831.html
     September 01, 2022 - healthcare organizations seldom learn from diagnostic events due to the complexity of identification and analysis … has a safety infrastructure in place and is interested in discovering improvement opportunities from analysis … Analysis of hospital-level readmission rates and variation in adverse events among patients with pneumonia

133. Fall Prevention Toolkit (doc file)
     talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_tools.docx
     August 03, 2017 - to audit incident reports of falls to see if the reports provide adequate information for root cause analysis … the information below may be used in conjunction with Tool 3O, “Postfall Assessment for Root Cause Analysis … preferably monthly Information on rates is disseminated to key stakeholders and staff Root cause analysis

134. When It Comes to High-Quality Healthcare, Diagnostic Safety Tops the List | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-tops-the-list.html
     March 01, 2024 - Another recent analysis in JAMA Internal Medicine estimated that 23 percent of patients treated at … engagement; healthcare professional education and training; health information technology; identification, analysis

135. Module 3: Best Practices in Fall Prevention—Slide Presentation | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-3/slides.html
     September 01, 2017 - Analysis of post-fall procedures , including clinical review and huddles. … Slide 44: Analysis of Huddles Shows Trends Preventable falls related to toileting: Notification … Slide 46: Root Cause Analysis After an injurious fall, collect data to reconstruct the event and … The analysis captures information from the patient, staff, and other witnesses about the fall. … Refer to Tool 3O: Post-Fall Assessment for Root Cause Analysis.

136. Module 3: Best Practices in Fall Prevention (doc file)
     talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_fall-prevention.docx
     January 01, 2013 - Root cause analysis When do you do it? … risk assessment Adult unit fall prevention care plan Post-fall huddle Root cause analysis … Slide 44 SAY: An analysis of post-fall huddle forms may show trends in preventable falls. … The analysis captures information from the patient, staff, and other witnesses about the fall. … Refer to Tool 3O: Post-Fall Assessment for Root Cause Analysis.

137. Patient Safety Organizations: A Summary of 2014 Profiles (pdf file)
     talkingquality.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
     January 01, 2014 - Err Is Human series, identifies the PSO program as an important tool for increased reporting and analysis … PSOs can analyze provider data and assist with root-cause analysis of individual events, thus identifying … number of contracted hospitals increased by 269 over this period. 4 aggregates those data for analysis … Lessons learned from the analysis of collected event reports by PSOs can be used to educate members … all members wishing to submit information on an adverse event to their PSO to perform a root-cause analysis

138. Development of the Patient-Centered Medical Home Item Set | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/cahps/surveys-guidance/item-sets/PCMH/Development-PCMH-Survey.html
     November 01, 2020 - Psychometric analysis. … This analysis informed the final 2.0 version of the PCMH Item Set. Public release.

139. TeamSTEPPS Fundamentals Course: Module 1 | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/teamstepps/instructor/fundamentals/module1/m1evidencebase.html
     March 01, 2014 - s (2008) meta-analysis on the science of team training illustrated that positive relationships exist … A meta-analysis. Hum Factors 2008;50:903-33. 10. Salas E, Burke CS, Stagl KC. … The effectiveness of managerial leadership development programs: a meta-analysis of studies from 1982 … Physician communication and patient adherence to treatment: a meta-analysis. … Information sharing and team performance: a meta-analysis.

140. EvidenceNow Executive Summary - New York City Cooperative (pdf file)
     talkingquality.ahrq.gov/sites/default/files/wysiwyg/evidencenow/cooperatives/evidencenow-executive-summary-nyc.pdf
     November 01, 2017 - characteristics drive differences in the external practice facilitation (PF) process: a comparative analysis … Facilitation in primary care settings to reduce risk factors for cardiovascular disease: Burnout analysis … Facilitation in primary care settings to reduce risk factors for cardiovascular disease: Baseline analysis