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161. 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.

162. AHRQ Training Leads to New Protocol at New York Health Department | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cquips0502.html
     October 01, 2014 - factor engineering, the video presentation of the Josie King story, introduction of the root cause analysis … evaluation protocol, improvement of the quality of root cause analysis, and a hands-on practicum on … root cause analysis. … NYSDOH developed a root cause analysis evaluation protocol as its required PSIC project during their … consistency in interpretations across the state and enhance expectations for thorough and credible analysis

163. Exhibit 5.10. Experiential Training and Project Activities | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit5-10.html
     November 01, 2014 - Pareto, or "80/20," analysis is often used to reveal core sources of adverse outcomes. … Gap analysis: Conducts a multistep gap analysis beginning with a G emba walk cc followed by documentation … The project team then prioritizes barriers, conducts a root cause analysis, and completes its gap analysis

164. Chapter 3. Designing and Testing Methods to Stratify Risk of Surgical Site Infections | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ssi/ssi3.html
     April 01, 2018 - Standard statistical analysis is carried out on each imputed dataset, producing multiple analysis results … These analysis results are then combined to produce one overall analysis. … Multivariate analysis of the datasets, including each procedure as a binary variable. … Male gender was only significant in the derivation analysis. … Multivariate analysis of the datasets including only total knee surgery.

165. Candor-Impguide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/candor-impguide.pdf
     April 01, 2016 - ■ Component 4: Event Investigation and Analysis. … These activities include: ■ Obtaining organizational buy-in and support ■ Conducting a gap analysis … Figure 3: CANDOR Process Implementation Team Structure Event Reporting, Investigation and Analysis … Event Reporting, Investigation, and Analysis Team. … Event Reporting, Investigation, and Analysis Team Event Reporting, Investigation, and Analysis Team

166. Identify Defects Through Sensemaking, Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/identify/notes.html
     December 01, 2012 - Root Cause Analysis: Causal Tree Worksheet 6 Slide 16. Root Cause Analysis Example 6 Slide 17. … The Failure Mode and Effects Analysis tool provides a way to conduct a step-by-step analysis staff can … A failure mode and effects analysis is different from a root cause analysis, in that the failure mode … If the analysis of an event lists only one type, then it is likely the analysis is incomplete. … This sequence of analysis is very important.

167. Mod4-System-Focused-Event-Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-system-focused-event-guide.pdf
     April 01, 2016 - Purpose: To help teams adopt a system-focused approached to event investigation and analysis. … Event Reporting, Investigation, and Analysis Team. … System-Focused Event Investigation and Analysis Guide – 5 7. … 10 – System-Focused Event Investigation and Analysis Guide 6. … What is the output from the in-depth investigation and analysis?

168. Chapter-6 - Carbapenem-Resistant-Enterobacteriaceae (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/carbapenem-resistant-1.pdf
     March 01, 2020 - Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices … This meta-analysis found that the greatest pooled ORs were for carbapenem exposure (OR = 4.71, 95% CI … 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

169. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.html
     July 01, 2023 - Learn From Defects Form Failure Mode and Effects Analysis   Probabilistic Risk Assessment … Failure Mode and Effects Analysis Probabilistic Risk Assessment Tools to examine defects … Slide 13: Root Cause Analysis: Causal Tree Worksheet 6 Image: The causal tree is made up of five … Patient safety analysis training. [ Columbia University's Digital Knowledge Ventures is no longer in … Patient safety analysis training. [ Columbia University's Digital Knowledge Ventures is no longer in

170. More Than 80 Percent of Antibiotics Prescribed Before Dental Procedures Are Unnecessary, Analysis Concludes | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/668.html
     June 01, 2019 - More Than 80 Percent of Antibiotics Prescribed Before Dental Procedures Are Unnecessary, Analysis Concludes … Headlines More Than 80 Percent of Antibiotics Prescribed Before Dental Procedures Are Unnecessary, Analysis … More Than 80 Percent of Antibiotics Prescribed Before Dental Procedures Are Unnecessary, Analysis Concludes … An analysis of diagnoses that drive readmission: what can we learn from the hospitals in Southern New

171. Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flink.pdf
     April 09, 2004 - , root-cause analysis, education, and dissemination. … activities or statewide analysis of individual reporting codes. … Dissemination of information and analysis The NYSDOH disseminates data analysis results using various … Code 915—Unexpected Death Analysis presented at January and May 2003 meetings. … This added structure to the reports and allowed more meaningful analysis to occur.

172. Impact of a pediatric-focused medical home learning collaborative on preventable emergency department visits by publicly-insured children in Massachusetts (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/chipra-medical-home-academyhealth.pdf
     December 12, 2015 - Without Chronic Disease • Our analysis of preventable ED use compared categories 1 and 2 (any chronic … No Chronic Disease) • Longitudinal analysis, unadjusted percentages Longitudinal … • In the repeat cross-section analysis, we see a marginal association between LC participation and … • The longitudinal analysis shows stronger effects, specifically for children with chronic conditions … Results (Question 1) Results (Question 2) Results (Question 2): By PMCA Category Longitudinal Analysis

173. HCBS CAHPS Survey Database: What You Need to Know - WOODWARD (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/hcbs-webcast-051623-woodward.pdf
     June 21, 2023 - Analyzing CAHPS Data: https://www.medicaid.gov/medicaid/quality- of-care/downloads/hcbscahps-appk-data-analysis-guide.pdf … hcbscahps-admin-ta-guide.pdf https://www.medicaid.gov/medicaid/quality-of-care/downloads/hcbscahps-appk-data-analysis-guide.pdf … https://www.medicaid.gov/medicaid/quality-of-care/downloads/hcbscahps-appk-data-analysis-guide.pdf mailto … the adoption and successful administration of the HCBS CAHPS Survey across states • Supports data analysis

174. Implementation Guide for the CANDOR Process: Appendix B | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/impguide/apb.html
     August 01, 2022 - Event Reporting, Investigation, And Analysis Team     Event Reporting, Investigation, and Analysis … Team Lead Implements the event reporting, investigation, and analysis processes; reports to the CANDOR … Implementation Team Leader Director of Risk Management Event Reporting, Investigation, and Analysis … Assists the Team Lead with developing, educating, and implementing the event reporting, investigation and analysis

175. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/actionplan-trip-facguide.docx
     January 01, 2017 - We will also discuss gap analysis and test of change. … You will be able to define gap analysis and list the principles of test of change. … At this point you can begin to perform a gap analysis. … SAY: We mentioned gap analysis earlier. … , developed a unit-based gap analysis tool and published it on their Web site.

176. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
     May 01, 2017 - Learn From Defects Form Failure Mode and Effects Analysis Probabilistic Risk Assessment Causal … - Failure Mode and Effects Analysis - Probabilistic Risk Assessment Tools to examine defects or … Patient safety analysis training. … Patient safety analysis training. … Patient safety analysis training.

177. Introducing Electronic Screening Tools for Developmental Delay and Autism into Pediatric Primary Care: Effects on Screening Documentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/Natzke-presentation.pdf
     December 01, 2015 - results automatically entered into EHR • Provider can view and act on results during visit 7 Analysis … and Findings 8 Analysis • Data: The Children’s Hospital of Philadelphia (CHOP) EHR data, and … evaluation and early intervention services more easily or consistently 14 Next Steps: Further Analysis … • PolicyLab at CHOP plans to conduct longitudinal analysis – Including all payers and all office … • Expect to complete analysis in December 2015, with results available in spring 2016 15 For

178. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/strat.html
     October 01, 2017 - Root Cause Analysis for New Falls     5. Weekly Falls Risk Huddle     6. … Root Cause Analysis for New Falls     4. … Root Cause Analysis for New Falls     3. … Root Cause Analysis for New Falls     4. Weekly Falls Risk Huddle     5.

179. 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/wysiwyg/research/findings/final-reports/26069-France-draft-1.pdf
     March 29, 2022 - 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.

180. 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/wysiwyg/research/findings/final-reports/26069-France-report.pdf
     March 29, 2022 - 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.