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201. 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/wysiwyg/research/findings/final-reports/joseph1-report.pdf
     January 01, 2012 - 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

202. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
     July 01, 2023 - Root Cause Analysis. Failure Mode and Effects Analysis. Probabilistic Risk Assessment. … Mode and Effects Analysis, and the Probabilistic Risk Assessment. … Here is an example of a root cause analysis causal tree template. … 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.

203. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
     January 01, 2024 - Sensitivity analysis. … Sensitivity analysis. … Sensitivity analysis. … Sensitivity analysis. … Sensitivity analysis.

204. Implementation Guide for the CANDOR Process: Appendix B | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/capacity/candor/impguide/apb.html
     February 01, 2017 - 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

205. 0129Table9 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0129table9.pdf
     January 01, 2008 - Table 9 – Analysis of Disparities in Readmission Risk Based on Race/Ethnicity 2005-2009 AHRQ Revisit … Black 1.18 [1.13 – 1.22] Hispanic 1.24 [1.20 – 1.29] Other 1.03 [0.98 – 1.07] Table 10 – Analysis … 0.98 [0.94 - 1.02] Mixed 1.07 [0.91 - 1.26] Native American 1.09 [0.99 - 1.20] Table 11 – Analysis

206. Elements of an Evaluation Plan | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/assess/evaluation-plan.html
     January 01, 2023 - This may include a qualitative data analysis software program. … Staff who have skills in qualitative data analysis. … Staff who have skills in qualitative data analysis. … Data Analysis Analysis methods vary by how you collect the data. … Who will do the analysis?

207. Sensemakingnotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
     August 08, 2012 - 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 … analysis focuses on the main cause of the event. … 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.

208. Menu of Implementation Strategies - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallspximplstrat.pdf
     November 02, 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. Pharmacy Consultant Monthly Medication Review 4. … Root Cause Analysis for New Falls 4. Weekly Falls Risk Huddle 5.

209. AHRQ Helps Establish Consortium Aimed at Using Data To Improve Care for COVID-19 Patients | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/749.html
     February 01, 2021 - Analysis Recommends Against Skipping Earliest Vaccines Developed for COVID-19 . … Analysis Recommends Against Skipping Earliest Vaccines Developed for COVID-19 A new analysis of potential … For example, the analysis indicates that, if a vaccine with 50 percent efficacy becomes available when … System issues leading to "found-on-floor" incidents: a multi-incident analysis . … Analysis of incident reports from a Patient Safety Organization.

210. Study of Privately Insured Patients Shows Nearly One in Four Antibiotic Prescriptions Were Unnecessary | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/648.html
     January 01, 2019 - New AHRQ Analysis Focuses on Opioid Use Among Women . … Michigan Medical School and Brigham and Women's Hospital/Harvard Medical School conducted a combined analysis … The analysis provides the most comprehensive estimates to date of inappropriate prescribing of antibiotics … New AHRQ Analysis Focuses on Opioid Use Among Women Opioid-related hospitalization rates among women … Access the AHRQ analysis .

211. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/learn-from-defects-slides.html
     May 01, 2017 - Sensemaking Tools Staff Safety Assessment Discovery Form Safety Issues Worksheet Root Cause Analysis … Learn From Defects Form Failure Mode and Effects Analysis   Probabilistic Risk Assessment   … Failure Mode and Effects Analysis Probabilistic Risk Assessment Tools to examine defects or … 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

212. How To Manage Change
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module2/module2_managingchange_slides.pptx
     November 20, 2014 - (Tool 2A) Present the completed process analysis on one patient care unit. … Plan, Do, Study, Act is one systematic approach to analysis and implementation. … 14 Practice Insight Use of Shadowing To Assess Current Practices 15 Current Process Analysis (2C … ) Tool 2C 16 Current Process Analysis (2C) Let’s hear from the team member(s) who completed the … process analysis.

213. 194. Specific Populations and Other Topics (Continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide194.html
     October 01, 2014 - Population of Smokers Review of Evidence Low SES/limited formal education Meta-analysis … (2008): 5 studies met selection criteria and contributed to a 2008 Guideline meta-analysis comparing … counseling, abstinence rate = 17.7% [95% C.I. = 13.7%- 22.6%]) Interventions included in the meta-analysis

214. Fallpxtool2C (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool2c.docx
     January 28, 2013 - 2C: Current Process Analysis Background: Before beginning a quality improvement initiative, you need … QI Worksheet E, Current Process Analysis. … Determine if there are any gaps and problems in your current processes, and use the results of this analysis … Process Analysis Procedures Take time to brainstorm and listen to every team member. … At the end of the gap analysis, compile the results in a document that displays each step so that team

215. 2017 National Healthcare Quality and Disparities Report Measure Specifications (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/measspec-5.pdf
     January 01, 2017 - In 2013 and 2014, only one nationally weighted analysis file was created. … In 2013 and 2014, only one nationally weighted analysis file was created. … In 2013 and 2014, only one nationally weighted analysis file was created. … In 2013 and 2014, only one nationally weighted analysis file was created. … In 2013 and 2014, only one nationally weighted analysis file was created.

216. Plan Do Study Act (PDSA) Form (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/pdsa-form.pdf
     February 11, 2015 - Complete analysis of the data. Insert graphic analysis whenever possible. … Prediction: Learning (Comparison of questions, predictions, and analysis of data): Summary (Look … : Comparison of questions, predictions, and analysis of data: Summary: Activities/observations

217. Tool 6 (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/redtool6ref.html
     March 01, 2025 - Root cause analysis in health care: tools and techniques. … Patient Safety Primers: Root Cause Analysis. … Available at: https://psnet.ahrq.gov/primer/root-cause-analysis . National Quality Forum.

218. Tool 6 (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool6ref.html
     March 01, 2025 - Root cause analysis in health care: tools and techniques. … Patient Safety Primers: Root Cause Analysis. … Available at: https://psnet.ahrq.gov/primer/root-cause-analysis . National Quality Forum.

219. Washington University Comparative Effectiveness Administrative Data Repository (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/fraser_r24grant.pdf
     September 01, 2013 - This enhancement included developing existing server infrastructure for more efficient storage and analysis … Population-based analysis of the rising incidence of kidney cancer in the United States: Evaluation … Age at surgery not BMP exposure predicts cancer after BMP exposure: Analysis of 127,087 cases. … A population based analysis of contemporary rates of reoperation for penile prosthesis procedures. … State-level analysis of the contemporary utilization of radical prostatectomy in the United States.

220. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
     August 01, 2022 - Rather than answer this question now, it is best that the communicator highlight the analysis process … and commit to sharing the results of the event analysis with the patient and/or family after it has … Can I see a copy of the event analysis? … Be sure the communicator understands your organization's policy on sharing results of an event analysis … It is rarely helpful to share all event analysis findings.