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181. 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

182. 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

183. Module 2: How To Manage Change—Training Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-2/guide.html
     September 01, 2017 - Review and discuss the completed process analysis of one or more patient care units. … process analysis of ( patient care units ). … analysis to participants. … You completed and discussed the Current Process Analysis using Tool 2C. … You assigned who will do the Current Process Analysis and worked on the timeline for the analysis.

184. Module 2: How To Manage Change (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_fall-prevention.docx
     August 24, 2017 - Review and discuss the completed process analysis of one or more patient care units. … analysis of (patient care units). … analysis to participants. … You completed and discussed the Current Process Analysis using Tool 2C. … You assigned who will do the Current Process Analysis and worked on the timeline for the analysis.

185. 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.

186. Final Progress Report: A Pilot Study for Intrgrating Facility Information With Healthcare Information to Improve Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/anumba-report.pdf
     August 07, 2023 - These included case studies, structured interviews with domain experts, content analysis of standards … and guidance documents, process modeling (using BPMN), task analysis, use case development (using UML … ), failure mode effect analysis (FMEA), fault tree analysis (FTA), and cognitive walk-throughs. … These models served as a basis for further analysis of the cases. … Aggregating this information is crucial for pattern analysis, learning, and trending.

187. 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

188. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
     August 01, 2022 - Investigation and Analysis. Resolution. … Component 4: Event Investigation and Analysis . … Conducting a gap analysis. Building project teams. … Event Reporting, Investigation, and Analysis Team . … System-Focused Event Investigation and Analysis Guide .

189. 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.

190. 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.

191. 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.

192. 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

193. 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

194. Making Healthcare Safer Practices: 12. Infusion Pumps (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/infusion-pumps-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 the 12 studies included in this review, 5 were 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

195. Final Progress Report: Nurse Staffing Policy, Hospital Occupancy, Market Structure, and Patient Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/mchugh-report.pdf
     January 01, 2024 - The funding sources had no role in the study design; data collection, analysis, or interpretation; or … Staffing and skill mix analysis. … Safety net hospital analysis. … Patient outcomes analysis. … Patient outcomes analysis The results for this analysis are not finalized.

196. Final Progress Report: Re-engineering the Hospital Discharge for Patient Safety--Safe Practices Implementation Challenge Grant (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14289-Jack-draft-1.pdf
     January 19, 2005 - ; (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.”

197. Qualitative Methods Used in AHRQ-Funded Primary Care Research - Slide Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/qual-methods-pcr-080323.pptx
     January 01, 2025 - Third, I developed preliminary themes, which were iteratively refined with our full analysis team. … Doing Reflexive Thematic Analysis. … In Thematic Analysis: A Practical Guide; SAGE Publications Inc.: Thousand Oaks, CA, USA, 2022; pp. 1– … Getting your own house in order: Understanding what makes good reflexive thematic analysis to ensure … Next, over-thinking what’s “right” and “wrong” regarding methods and analysis choices in qualitative

198. Making Healthcare Safer Practices: 11. Patient Identification Errors in the Operating Room (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/patient-id-errors-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 https … 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

199. 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.

200. Learning Health System Research Programs Within Delivery Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/learning-health-systems/harrison-borsky-lhs-research-progams.pdf
     October 13, 2021 - • Findings ► Analysis framework & examples ► Comparing LHS program contributions • Implications: … Rapid Qualitative Analysis: Updates & Developments. VA HSR&D Cyberseminar September 29, 2020. … Can rapid approaches to qualitative analysis deliver timely, valid findings to clinical leaders? … A mixed methods study comparing rapid & thematic analysis. … Methods and Stages Rapid qualitative analysis Research Settings Analysis Framework Contributions