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3521. Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS Collaborative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-West_102.pdf
      March 31, 2008 - Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS Collaborative Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS Collaborative David R. West, PhD; Wilson D. Pace, MD; L. Miriam Dickinson, PhD; Daniel M. H…

3522. Appendix 2: CED Compiled Public Comment Themes (xls file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/ced-appendix2-comments.xlsx
      June 02, 2025 - Appendix 2: CED Compiled Public Comment Themes Summary_Out of Scope Comments There were many comments that were outside of the scope of this project in that they addressed the CED process rather including when and how it should be implemented. Multiple comments proposed that AHRQ should undertake a similar exercise …

3523. Final Progress Report: Multi-Method Proactive Risk Assessment (pdf file)
      www.ahrq.gov/sites/default/files/2024-12/pace-report.pdf
      January 01, 2024 - Final Progress Report: Multi-Method Proactive Risk Assessment Title: Multi-Method Proactive Risk Assessment PI and Team: Wilson D. Pace, MD – Principal Investigator David R. West, PhD – Co-investigator Stephen Ringel, MD – Co-investigator Susan West, RN – Co-investigator Doug Fernald, MS – Project Manager Caroline …

3524. Using Patient Complaints to Promote Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Pichert_51.pdf
      March 22, 2008 - Using Patient Complaints to Promote Patient Safety Using Patient Complaints to Promote Patient Safety James W. Pichert, PhD; Gerald Hickson, MD; Ilene Moore, MD, JD, FCLM Abstract Patients can help promote safety and reduce risk in several ways. One is to make known their concerns about their health care e…

3525. 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive in a Single Hospital? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Meliones_40.pdf
      January 01, 2006 - 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive in a Single Hospital? 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive …

3526. Improving Management of Test Results that Return After Hospital Discharge - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/k08hs018539-were-final-report-2014.pdf
      January 01, 2014 - Improving Management of Test Results that Return After Hospital Discharge - Final Report Improving Management of Test Results that Return After Hospital Discharge Principal Investigator Martin C. Were Team Members William  M. Tierney, MD Project Time  Period: September 30, 2009 through  May 31, 2014 Feder…

3527. Ced -Appendix-2 (xls file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/ced%20-appendix-2.xlsx
      October 08, 2025 - Summary_Out of Scope Comments There were many comments that were outside of the scope of this project in that they addressed the CED process rather including when and how it should be implemented. Multiple comments proposed that AHRQ should undertake a similar exercise to this one, with the goal of revising the CED p…

3528. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49480/psn-pdf
      May 01, 2005 - care are considered, and that clinical practitioners rarely fully appreciate their own limitations in analyzing

3529. Production Pressures | PSNet
      psnet.ahrq.gov/web-mm/production-pressures
      November 16, 2022 - Safe organizations put effort into analyzing the work system and attempting to predict and plan for workload

3530. Medication Reconciliation Technology to Improve Quality of Transitional Care - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs018183-weiner-final-report-2013.pdf
      January 01, 2013 - We are analyzing approximately 4,400 medication records and 370 observations for potential adverse drug

3531. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
      January 01, 2003 - Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities 395 Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities Sharon Conrow Comden, David Marx, Margaret Murphy-Carley, Misti Hale Abstract Objectives: State agenc…

3532. Final Progress Report: Demonstration of Quality Improvement of Medication Therapy Management Services (pdf file)
      www.ahrq.gov/sites/default/files/2024-12/doucette-report.pdf
      January 01, 2024 - Final Progress Report: Demonstration of Quality Improvement of Medication Therapy Management Services AHRQ Grant Final Report Project Title: Demonstration of Quality Improvement of Medication Therapy Management Services Principal Investigator: William R. Doucette, PhD Email: william-doucette@uiowa.edu (319) 335-8…

3533. Final Progress Report: Medication Reconciliation: Bridging Communications Across the Continuum of Care (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/muller-report.pdf
      January 01, 2024 - Final Progress Report: Medication Reconciliation: Bridging Communications Across the Continuum of Care Title: Medication Reconciliation: Bridging Communications Across the Continuum of Care Principal Investigator and Team Members: Melinda Muller, MD, Lynn Belcher, RPh, Melissa Blanchard, MP, Amy Caster-Winegeart, …

3534. Cloud Care: A Feasibility Study of Cloud-Based Care Plans for Children with Medical Complexity - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs027465-desai-final-report-2023.pdf
      January 01, 2023 - Cloud Care: A Feasibility Study of Cloud-Based Care Plans for Children with Medical Complexity - Final Report CLOUD CARE: A FEASIBILTY STUDY OF CLOUD-BASED CARE PLANS FOR CHILDREN WITH MEDICAL COMPLEXITY Team Members: Arti D. Desai, MD, MPSH (Principal Investigator) Dylan Kinard, BS Katherine Hawley, RN …

3535. 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 - implement comprehensive, accessible, and user-friendly systems for recording, monitoring, tracking, and analyzing … policies and procedures for deploying systems for clinical performance assessment as well as recognizing, analyzing

3536. InfoSAGE Information Sharing Across Generations and Environments - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r01hs021495-safran-final-report-2019.pdf
      January 01, 2019 - InfoSAGE Information Sharing Across Generations and Environments - Final Report AHRQ Grant R01HS21495 Final Report 05/31/2019 Title InfoSAGE Information Sharing Across Generations and Environments Principal Investigator (PI) Charles Safran MD Organization Beth Israel Deaconess Medical Center Inclusive Dates …

3537. R18Hs017163-Baker-Final-Report-2011 (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017163-baker-final-report-2011.pdf
      January 01, 2011 - 1 FINAL REPORT Using Precision Performance Measurement to Conduct Focused Quality Improvement Principal Investigator: David W. Baker, MD, MPH Team Members: Steven Persell, MD, MPH; Abel Kho, MD; Nancy Dolan, MD; Muriel Jean- Jacques, MD Organization: Northweste…

3538. AHRQ Slide Template 2004 (ppt file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/spectorhudak.ppt
      December 01, 2013 - AHRQ Slide Template 2004 On-Time Prevention Program for Long Term Care: Clinical Decision Support William Spector, Ph.D. AHRQ Sandra Hudak, MS RN SLH Clinical Consulting Presentation at AHIMA June 17, 2013 Baltimore, MD Using HIT for Prevention in Nursing Homes Pressure ulcers, falls, and preventable hospitali…

3539. Value and Efficiency Supplemental Items for Hospitals and Medical Offices - PERSILY (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/valuewebcast-persily.pdf
      June 02, 2025 - Value and Efficiency Supplemental Items for Hospitals and Medical Offices - PERSILY 43 First Hand Experience: The AHRQ Hospital Value and Efficiency Item Set Cynthia Persily, PhD Chief Executive Officer Highland Hospital Charleston, West Virginia cpersily@highlandhosp.com 43 mailto:cpersily@highlandhosp.com …

3540. 5 Tk1 T2-Working With A Lab Final (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK1_T2-Working_with_a_lab_final.pdf
      October 01, 2016 - Nursing Home Antimicrobial Stewardship Guide Help Clinicians Choose the Right Antibiotic Toolkit 1. Working With a Lab To Improve Antibiotic Prescribing Tool 2. Step-by-Step Guide to Working With a Laboratory To Obtain an Antibiogram 1. Contact the nursing home’s lab to inquire about creating an antibiog…