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421. Final Progress Report: An Intervention to Reduce Falls Among Adults with Intellectual Disability (pdf file)
     www.ahrq.gov/sites/default/files/2024-04/bonardi-report.pdf
     January 01, 2024 - because of cognitive and functional limitations specific to this population.v Prior Analyses: In an analysis … Measures collected for analysis Falls Risk Screening Tool VRS Evaluation Activities of Daily Living ( … An item-level analysis of each component of the VRS Falls Risk Screening Tool (FRST) will be performed … Analysis continues at UMMS/Shriver with the same project team. … Data analysis will be completed by October 30, 2015, with manuscript submission targeted for December

422. Children’s Hospital Uses AHRQ’s Pediatric QI Toolkit To Bring Physicians Together To Reduce CLABSIs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/standalone_pdi_casestudy.pdf
     December 01, 2015 - Practices for Central Venous Catheter (CVC)-Related Bloodstream Infections (Tool D.4x) • Gap Analysis … Practices for Central Venous Catheter (CVC)-Related Bloodstream Infections (Tool D.4x) and the Gap Analysis … The results of the gap analysis revealed the areas in which the hospital’s practices diverged from … Implementing a Clinical Intervention In addition to engaging physicians, the gap analysis helped the … Schroeder found that she was easily able to change the tools—such as the gap analysis and implementation

423. 197. Specific Populations and Other Topics (Continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide197.html
     October 01, 2014 - Smokers Review of Evidence Psychiatric disorders including substance use disorders Meta-analysis … (2008): Four studies met selection criteria and were relevant to a 2008 Guideline meta-analysis comparing

424. Develop and Improve Your Stewardship Program | Agency for Healthcare Research and Quality
     www.ahrq.gov/antibiotic-use/acute-care/improve/index.html
     June 01, 2021 - The gap analysis should be completed by all ASPs to ensure that all essential components are present. … Implementation Guide for the AHRQ Safety Program for Acute Care (PDF, 328 KB) Gap Analysis Tool (

425. Final Progress Report: Connected Emergency Care (CEC) Patient Safety Learning Lab (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/hinson-levin-report.pdf
     January 01, 2025 - Innovation cycles included (1) problem analysis, (2) solution design, (3) solution development, (4) … Our first year was dedicated to broad problem analysis that determined our team’s trajectory. … We performed structured observations using task analysis methods and created process and value stream … Over the analysis period, we observed a total of 3028 bed-hours saved per week, translating to 7500 … Although our granular EHR-derived data repository facilitated in-depth analysis, it also meant that

426. Re-engineering for Accurate, Timely, and Communicated Diagnosis of Cardiovascular Disease in Women (DREAM Lab) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/dream-lab-long-desc.html
     August 01, 2025 - these aims, the lab implemented nine interwoven workstreams, including environmental scanning, data analysis … Evaluation of a natural language processing approach to identify diagnostic errors and analysis of safety … Evaluation of a natural language processing approach to identify diagnostic errors and analysis of safety

427. Graphics for Section 5. Evidence or Other Justification for the Focus of the Measure (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-135-graphics-section-5.pdf
     November 26, 2013 - Meta-analysis A meta-analysis of three randomized trials found that initiation of penicillin prophylaxis … powered and conducted randomized controlled trial (RCT); well-conducted systematic review or meta-analysis

428. Final Progress Report: Weekend Effects and the July Phenomenon in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/weissman-report.pdf
     January 01, 2024 - In a subgroup analysis of surgical complications, we restricted the population to patients who underwent … Statistical Analysis and Control for Confounding Weekends were defined as any Saturday or Sunday (the … In a separate analysis, we included all major federal holidays (New Year’s Day, Martin Luther King’s … The data from all states were combined for the analysis in order to ensure that the size of the study … In a subgroup analysis, we hypothesized that certain procedures that require specialist surgeons or

429. Final Progress Report: What Is Patient Safety in the Medical Home? (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/dy-report.pdf
     January 01, 2024 - Qualitative comparative analysis was used to examine the relationship between contextual issues, patient … Analysis: A multidisciplinary coding team first identified an initial set of codes a priori using the … We used MAXQDA 12 to organize the data and facilitate analysis. … Analysis: • (Paper 6): We used coincidence analysis, a novel method based on set theory and Boolean … Constructing Grounded Theory: A Practical Guide through Qualitative Analysis.

430. Tool 2: Readmission Review Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool2_readm_review.docx
     June 02, 2025 - Root Cause Analysis and Lessons Learned (2-3 minutes each) The purpose of a root cause analysis is to … Hospital Guide to Reducing Medicaid Readmissions for an example of interview findings and root cause analysis

431. A Future Vision for Better Diagnostic Outcomes | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load5.html
     May 01, 2024 - frontline clinicians during the development of new technology to ensure adequate system testing (e.g., analysis … In addition, at this hospital, cognitive task analysis was coupled with task-evoked pupillary eye tracking … This analysis resulted in an information visualization system that minimizes extrinsic cognitive load

432. Final Topic Refinement Document - Role of Liquid Biopsy in Detection and Management of Cancer in the Medicare Population (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/liquid-biopsy-topicrefinement.pdf
     July 29, 2021 - MA = meta-analysis; RCT = randomized controlled trial; SR = systematic review Draft Population, … The types and breadth of analysis possible is significant, and as such, Illumina recommends focusing … Recent large studies comparing the performance of ctDNA analysis to tissue biopsy have demonstrated … Freenome therefore suggests that AHRQ include such an analysis if KQ1 is retained. … Biopsies are a cornerstone of traditional pathological analysis of disease.

433. Final progress Report: Anticholinergics and Cognitive Decline in the Elderly with Depression (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/aparasu-report.pdf
     January 01, 2024 - Cases for this analysis were ascertained based on dementia diagnosis in the MDS or CCW files. … , because prior falls history can mediate future fracture risk in the main 30-day analysis. … Results from the sensitivity analysis supported the main findings. … Dynamic risk analysis in retrospective matched pair studies of disease. … Design and analysis of case-control studies. Annu Rev Public Health 1982 3:29-54.

434. Quality Indicators Sensitive to Nurse Staffing in Acute Care Settings (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Savitz.pdf
     March 01, 2004 - • Unit of analysis. • Risk adjustment, if any. … Reports of indicators were further classified into these categories for analysis purposes. … From this process, we report the results of our analysis. … We found variation in unit of analysis across studies in the abstracted literature. … Meta-study of qualitative health research: a practical guide to meta-analysis and meta-synthesis.

435. Advances in Patient Safety: New Directions and Alternative Approaches | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advances-new-directions/index.html
     July 01, 2022 - The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis … Cause Analysis The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure … Common Cause Analysis: Focus on Institutional Change (   PDF , 387 KB ) Anne Marie Browne, et al. … Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes From Paper to … Failure Mode and Effects Analysis Based on In-Situ Simulations: A Methodology to Improve Understanding

436. Final Progress Report: Physician Perspectives Regarding the Use of Shared Decision Making in the Emergency Department (pdf file)
     www.ahrq.gov/sites/default/files/2024-05/schoenfeld-report.pdf
     January 01, 2024 - The codebook was developed using a directed approach to qualitative content analysis: we combined a … Our data analysis focused on three contexts: 1. … General practitioners’ views on shared decision making: a qualitative analysis. … Qualitative Data Analysis: A Methods Sourcebook. … Three Approaches to Qualitative Content Analysis. Qual Health Res. 2005;15(9):1277–1288.

437. Building an Ambulatory Patient Safety Learning Laboratory for Diverse Populations (ASCENT) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/building-ambulatory-long-desc.html
     April 01, 2021 - of English, Chinese, and Spanish-speaking safety-net patients on clinician computer use: qualitative analysis … A qualitative analysis of outpatient medication use in community settings: observed safety vulnerabilities … Finding meaning in medication reconciliation using electronic health records: qualitative analysis in … misses related to multitasking on the electronic health record: observational study and qualitative analysis … Efficiency and interpretability of text paging communication for medical inpatients: a mixed-methods analysis

438. Health IT and Diagnostic Safety: A Human Factors and Systems Engineering Perspective (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/carayon-summit2016.pdf
     June 02, 2025 - IT-supported process for preventing and managing VTE AHRQ Grant 1R01HS022086 Human-centered design  Analysis … Work (sociotechnical) system of VTE diagnosis  Role network analysis [info gathering, info integration … Cues for VTE diagnosis  Table of cues  Comparative analysis of cues across 3 EDs and roles 3.

439. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-ref.html
     April 01, 2018 - Qualitative Analysis of Consumer Perspectives Chapter 4. … Environmental Scan of Patient Safety Education and Training Programs: Qualitative Analysis of Consumer

440. A Process-centered Tool for Evaluating Patient Safety Performance and Guiding Strategic Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Akins.pdf
     January 01, 2003 - Category 4: Measurement, Analysis, and Knowledge Management 4.1. … Category 4, Measurement, analysis, and knowledge management. 3. … Category 4, Measurement, analysis, and knowledge management. 2. … The step by step guide to failure modes and effects analysis. … risk analysis system.