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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.
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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.
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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.
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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
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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.
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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.
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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.
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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
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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.
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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.
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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