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141. Final Progress Report: Unexpected Clinical Events: Impact on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/weinger2-report.pdf
     January 01, 2024 - A sophisticated data collection and analysis system was designed and constructed. … Task Analysis of the Drug and Fluid Administration Process. … Over a multi-year period, we collected a total of 221 cases for a between-subjects analysis. … Runciman WB, Webb RK, Lee R, Holland R: System failure: an analysis of 2000 incident reports. … Task Analysis of the Drug and Fluid Administration Process.

142. Appendix 1. Bibliography of Recent Reviews of Self-Management Support Effectiveness | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ptmgmt/appendix1.html
     July 01, 2018 - Closing the quality gap: a critical analysis of quality improvement strategies ; Volume 5. … Meta-analysis: chronic disease self-management programs for older adults. … Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic … In: Shojania KG, McDonald KM, Wachter RM, et al., eds., Closing the quality gap: a critical analysis … Meta-analysis of published reports. BMJ 2002;325(7370):925.

143. Making Healthcare Safer Practices: 10. Harms Due to Opioids (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/opioids-1.pdf
     March 01, 2020 - Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices http … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices

144. Instructions for Analyzing Data from CAHPS Surveys (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/helpful-resources/analysis/2020-instructions-for-analyzing-data.pdf
     January 01, 2020 - What Does the CAHPS Analysis Program Do? … What Does the CAHPS Analysis Program Do? … Pre-Analysis Decisions The CAHPS Analysis Program offers the user a number of options for analyzing … SAS Data Sets Generated by the CAHPS Analysis Program The CAHPS Analysis Program creates permanent … What Does the CAHPS Analysis Program Do? 3. What Is Included in the CAHPS Analysis Program? 4.

145. Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/hai/pfp/haccost2017.html
     November 01, 2017 - Comparison of random and fixed effect meta-analysis models Exhibit 7. … Summary of meta-analysis additional cost estimates Exhibit 8. … Summary of meta-analysis excess mortality estimates Exhibit 9. … ↓ Meta-Analysis 7) Construct dataset: Use Stata 14 meta-analysis package to create a dataset … using Stata 14 (StataCorp LP) meta-analysis packages.

146. Toolbox Contents | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/toolcon/index.html
     June 01, 2020 - Indicators Included Availability Users Comparisons and Trends Service Delivery and Units of Analysis … Included Users Comparisons and Trends Benchmarking and Databases Service Delivery and Units of Analysis … Included Users Comparisons and Trends Benchmarking and Databases Service Delivery and Units of Analysis … Included Users Comparisons and Trends Benchmarking and Databases Service Delivery and Units of Analysis … Making Comparisons Databases and Benchmarks Trends Over Time Service Delivery Systems Unit of Analysis

147. Appendix C. Article Exclusion List with Reason for Exclusion | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/clabsi-final-companion/clabsicompapc.html
     January 01, 2013 - Review, meta-analysis and systematic review articles DiazGranados CA, 2005 Comparison of … Review, meta-analysis and systematic review articles Fraher MH, 2009 Cost-effectiveness of … Review, meta-analysis and systematic review articles Gagne JJ, 2006 Costs associated with … Published before 2002 Haley RW, 1998 Cost-benefit analysis of infection control activities … Review, meta-analysis and systematic review articles Stone PW, 2002 A systematic audit of

148. Final Progress Report: Leveraging Existing Assessments of Risk Now (LEARN) Final Report (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/woods2-report.pdf
     January 01, 2025 - Methods: The LEARN method consists of a meta-analysis of existing risk assessment. … Many FMEA risk results were from analysis conducted on different processes. … Scope: Develop and document scope statement prior to start of analysis 2. … LEARN (Leveraging Existing Assessment of Risks Now) A Meta-Analysis of Risk Results. … Meta-Assessment of Health Care Failure Mode and Effects Analysis Quality.

149. AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/overviewhandouts3.html
     December 01, 2017 - Root Cause Analysis for New Pressure Ulcers        6. Skin Rounds        7. … Root Cause Analysis for New Pressure Ulcers        6. Skin Rounds        7. … Root Cause Analysis for New Pressure Ulcers        6. … Root Cause Analysis for New Pressure Ulcers        9. Skin Rounds        10. … Root Cause Analysis for New Pressure Ulcers        7.

150. Final Progress Report: Re-engineering the Hospital Discharge for Patient Safety--Safe Practices Implementation Challenge Grant (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/jack-report.pdf
     January 01, 2024 - ; (3) root cause analysis of high utilizers; (4) qualitative interviews with rehospitalized patients … , root cause analysis, qualitative research, probabilistic risk assessment, embodied conversational … Analysis …………………………………...………………...7 5.4.2 Results of Qualitative Analysis …………………………………………………….7-8 … ; (4) qualitative study; and (5) root cause analysis. … A modest economic analysis is also suggested along with a project evaluation component.”

151. Chapter-3 - Sepsis Recognition (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/sepsis-1.pdf
     March 01, 2020 - Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices … of Existing and Emerging Patient Safety Practices Making Healthcare Safer III: A Critical Analysis … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices

152. Chapter-8 - Diabetes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/diabetes-1.pdf
     March 01, 2020 - Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices … The analysis of variance indicated that there were statistically significant differences between the … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices

153. Final Progress Report: Improving Safety and Quality with Outpatient Order Entry (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/gandhi-report.pdf
     January 01, 2024 - Aim 3 • Cost-Benefit Analysis. … Aim 3 Cost-Benefit Analysis. … Major Components of Cost-Benefit Analysis. … Aim 3 Cost-Benefit Analysis. … The cost-benefit analysis requires data and analysis from Aim 1 and Aim 2; therefore, results are not

154. Nutrition Research Series: Volume 3: Reporting of Systematic Reviews of Micronutrients and Health: A Critical Appraisa (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/nutrtp3.pdf
     March 01, 2009 - ,” or “pooled analysis.” … A meta-analysis. JAMA 1993;269:898-903. 76. Aminbakhsh A, Mancini J. … Folate and risk of breast cancer: a meta-analysis. … A meta-analysis of published trials. J Hyperten 1991;9:465-73. 156. … Fluoride supplements and fluorosis: a meta-analysis.

155. AHRQ Final report: Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/joseph1-report.pdf
     January 01, 2024 - Highly rated design tools included simulation, process analysis, link analysis, balanced scorecard, … • Root cause analysis (RCA) • Failure mode and effects analysis (FMEA) • Simulation • Work sampling … Other tools, such as process analysis and root cause analysis (aggregated data from RCAs being most … The most generalizable tools included link analysis, process analysis, balanced scorecard, and work … Design for patient safety tool summaries • Link analysis • Root cause analysis (RCA) • Failure mode

156. Evaluating and Predicting Patient Safety for Medical Devices with Integral Information Technology (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Zhang.pdf
     January 01, 2004 - Four components of a complete human factors engineering analysis Functional Analysis: identify top … Contents for System Implementation: Multiple Levels of Analysis User Analysis: identify characteristics … and extended hierarchical task analysis is a typical task analysis. … Hierarchical task analysis and its extension Hierarchical task analysis (HTA), one of the most widely … Traditional hierarchical task analysis and extended hierarchical task analysis.

157. Making Healthcare Safer Practices: 14. Delirium (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/delirium-1.pdf
     March 01, 2020 - Delirium in older hospitalized patients Making Healthcare Safer III: A Critical Analysis of Existing … Effectiveness of multicomponent nonpharmacological delirium interventions: A meta-analysis. … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices

158. Final Progress Report: The Role of Collective Mindfulness in Delivering Reliable and Safe Perioperative Care to Neonates (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/france-report.pdf
     January 01, 2024 - Analysis Plan Aim 1. … analysis plan in Aim 1 to facilitate the concordance analysis of the two measures. … Random safety auditing, root cause analysis, failure mode and effects analysis. Clin Perinatol. … Analysis Plan Aim 1. … analysis plan in Aim 1 to facilitate the concordance analysis of the two measures.

159. Chapter-2 - Failure-To-Rescue (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/failure-to-rescue-1.pdf
     March 01, 2020 - Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices … Three of these studies were also covered in a systematic review/meta-analysis. … Rapid response systems: a systematic review and meta- analysis. … Rapid response teams: a systematic review and meta- analysis.

160. Webinar 2: Analyze Data and Patient/Caregiver Perspectives (Section 1 of the Guide): Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/guide/web2.html
     December 01, 2017 - Describe the 15-part data analysis to understand all-payer and payer specific readmissions at your hospital … Data Analysis. Readmission Review. Hospital Inventory. Community Inventory. … Analysis Slide 8: Why Analyze Your Own Data? … Source: Massachusetts Center for Health Information and Analysis  and Jiang et al. … Slide 16: Data Analysis Tool Images: Three screenshots display the Data Analysis Tool.