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441. Improving Health Information Technology (IT) Patient Safety: A Resource List for Users of the AHRQ Health Information Technology Supplemental Item Set (pdf file)
     talkingquality.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

442. Nonadherence With Guidelines Associated With Cardiac Surgery Infection | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/news/newsletters/e-newsletter/873.html
     July 01, 2023 - A national analysis of ED presentations for early pregnancy and complications: implications for post-Roe

443. PS Grantee Report | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/research/findings/final-reports/index.html?page=8
     September 01, 2005 - Grant Number: R13 HS 014112 Topic(s): Education and Training Publication Date: May 2005 Risk Analysis

444. Data Resources | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/data/resources/index.html?page=4
     One of the most distinctive features of the NEDS is its large sample size, which allows for analysis

445. AHRQ Safety Program for Perinatal Care: Safe Medication Administration: Oxytocin (doc file)
     talkingquality.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

446. TeamSTEPPS Module 1: Introduction (Instructor Guide) (pdf file)
     talkingquality.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

447. Module 5: How To Measure Fall Rates and Fall Prevention Practices—Training Guide | Agency for Healthcare Research and Quality
     talkingquality.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

448. Equity Is Essential to Health Care Quality Improvement: National Academy of Medicine Discussion Paper | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/news/newsletters/e-newsletter/781.html
     September 01, 2021 - Thematic analysis of nurses' experiences with The Joint Commission's medication management titration

449. Medicare Pay-for-Performance Programs Not Linked to Consistent Quality, Safety Improvements | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/news/newsletters/e-newsletter/829.html
     August 01, 2022 - palliative care into ambulatory care of noncancer serious chronic illness: mixed methods review and meta-analysis

450. Search Evidence-Based Reports | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/research/findings/evidence-based-reports/search.html?page=3
     October 01, 2022 - Affiliation: Pacific Northwest EPC—Oregon Health & Science University Report Status: Final Analysis

451. AHRQ Views: Biden Administration Tackles Financial Strains on Healthcare Consumers | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/news/newsletters/e-newsletter/892.html
     December 01, 2023 - Patient safety incidents in endoscopy: a human factors analysis of non-procedural significant harm incidents

452. Patient Narratives Can Catalyze Staff Improvement and Bolster Survey Scores | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/news/newsletters/e-newsletter/900.html
     February 01, 2024 - A qualitative study combining human factors/ergonomics and social science analysis .

453. AHRQ Stats: Relationship Between Electronic Nicotine Use and General Health | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/news/newsletters/e-newsletter/903.html
     March 01, 2024 - Medication management strategies by community-dwelling older adults: a multisite qualitative analysis

454. Bleeding Risks Increase When Blood Thinners and Aspirin Are Taken Together | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/news/newsletters/e-newsletter/902.html
     February 01, 2024 - may work with administrative protocols, gain access to AHRQ-sponsored datasets and apply statistical analysis

455. Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles: Facilitator Notes | Agency for Healthcare Research and Quality
     talkingquality.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

456. Resource List - AHRQ Medical Office Survey (pdf file)
     talkingquality.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.

457. SOPS® Value and Efficiency Supplemental Items for the SOPS Hospital Survey - Spanish (doc file)
     talkingquality.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

458. Chsp-Accomplishments-Report-2021 (pdf file)
     talkingquality.ahrq.gov/sites/default/files/wysiwyg/chsp/CHSP-accomplishments-report-2021.pdf
     January 01, 2021 - measures across and within APCDs from four States to describe how APCDs can be used for multistate analysis … Accomplishments, 2015-2020 13 The RAND Center selected 24 health systems for comparative case study analysis … Sepsis Quality in Safety-Net Hospitals: An Analysis of Medicare’s SEP-1 Performance Measure. … A Multilevel Analysis of Patient Engagement and Patient-Reported Outcomes in Primary Care Practices … on Health Information Technology Adoption and Use Across Different Data Sources: A Mixed- Methods Analysis

459. Communication Assessment Guide | Agency for Healthcare Research and Quality
     talkingquality.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.

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