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5621. Final Progress Report: Creating Learning Cultures Around Mistakes for Residents (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/hoff-report.pdf
      January 01, 2024 - Final Progress Report: Creating Learning Cultures Around Mistakes for Residents 1 Project Title: Creating Learning Cultures Around Mistakes for Residents Timothy J. Hoff, PhD, Principal Investigator University at Albany, SUNY School of Public Health Henry Pohl, MD, Co-Investigator Joel Bartfield, MD, Co-Investi…

5622. Final Progress Report: Measurement of Decision Quality in Coronary Artery Disease (pdf file)
      www.ahrq.gov/sites/default/files/2024-12/lin-report.pdf
      January 01, 2024 - Final Progress Report: Measurement of Decision Quality in Coronary Artery Disease Measurement of Decision Quality in Coronary Artery Disease Grace A. Lin, MD, MAS, Principal Investigator R. Adams Dudley, MD, MBA, Mentor Rita F. Redberg, MD, MSc, Co-mentor Organization: University of California, San Francisco …

5623. 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 Practices: 11. Patient Identification Errors in the Operating Room Patient Identification Errors in the Operating Room 11-1 11. Patient Identification Errors in the Operating Room Authors: Cori Sheedy, Ph.D., and Sonja Richard, M.P.H. Introduction In the first Making Health Care Safer …

5624. Primary Care Practice Facilitation Curriculum Module 9: Using Appreciative Inquiry with Practices (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-9-appreciative-inquiry.pdf
      September 01, 2015 - Primary Care Practice Facilitation Curriculum Module 9: Using Appreciative Inquiry with Practices Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov Primary Care Practice Facilitation Curriculum Module 9: Using Appreciative Inquiry with Practices …

5625. Can an Academic Health Care System Overcome Barriers to Clinical Guideline Implementation? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Quinn.pdf
      January 01, 2004 - Can an Academic Health Care System Overcome Barriers to Clinical Guideline Implementation? 291 Can an Academic Health Care System Overcome Barriers to Clinical Guideline Implementation? Debra Quinn, Mary Cooper, Lynn Chevalier, Jerry Balentine, Lawrence Kadish, Steven Walerstein, Fredric Weinbaum, Mark Ca…

5626. Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdf
      July 01, 2003 - Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors 185 Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors Emily Beth Devine, Jennifer L. Wilson-Norton, Nathan M. Lawless, Thomas K. Hazlet, R…

5627. Identifying Barriers to the Success of a Reporting System (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harper.pdf
      March 01, 2004 - Identifying Barriers to the Success of a Reporting System 167 Identifying Barriers to the Success of a Reporting System Michelle L. Harper, Robert L. Helmreich Abstract Spurred by a controversial report from the Institute of Medicine on the prevalence of medical error, To Err Is Human, the medical profe…

5628. Medical Injury Identification Using Hospital Discharge Data (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Layde.pdf
      January 01, 2003 - Medical Injury Identification Using Hospital Discharge Data 119 Medical Injury Identification Using Hospital Discharge Data Peter M. Layde, Linda N. Meurer, Clare Guse, John R. Meurer, Hongyan Yang, Prakash Laud, Evelyn M. Kuhn, Karen J. Brasel, Stephen W. Hargarten Abstract Objective: Determine the feasi…

5629. The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Rudman.pdf
      January 01, 2004 - The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data 195 The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data William J. Rudman, Jessica H. Bailey, Carol Hope, Paula Garrett, C. Andrew Brown Abstract This paper examin…

5630. Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Baker_107.pdf
      March 30, 2008 - Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems Donald K. Baker, PharmD; James M. Hoffman, PharmD; Gregory A. Hal…

5631. Common Cause Analysis: Focus on Institutional Change (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Browne_5.pdf
      January 20, 2008 - Common Cause Analysis: Focus on Institutional Change Common Cause Analysis: Focus on Institutional Change Anne Marie Browne, MSN, RN; Robert Mullen, PharmD; Jeanette Teets, MSN, CRNP, RN; Annette Bollig, MSN, RN; James Steven, MD, SM Abstract The Children’s Hospital of Philadelphia has created a mechanism …

5632. The Use of Modest Incentives to Boost Adoption of Safety Practices and Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Meyer_41.pdf
      March 03, 2008 - The Use of Modest Incentives to Boost Adoption of Safety Practices and Systems The Use of Modest Incentives to Boost Adoption of Safety Practices and Systems Gregg S. Meyer, MD, MSc; David F. Torchiana, MD; Deborah Colton; James Mountford, MB, BCh; Elizabeth Mort, MD; Sarah Lenz; Nancy Gagliano, MD; Elizabet…

5633. The University of Wisconsin-Madison Multidisciplinary Graduate Certificate in Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Karsh.pdf
      April 08, 2004 - The University of Wisconsin-Madison Multidisciplinary Graduate Certificate in Patient Safety 269 The University of Wisconsin-Madison Multidisciplinary Graduate Certificate in Patient Safety Ben-Tzion Karsh, Pascale Carayon, Maureen Smith, Kathleen Skibinski, Bruce Thomadsen, Patricia Flatley Brennan, Mary Ell…

5634. Error Producing Conditions in the Intensive Care Unit (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
      February 26, 2008 - Error Producing Conditions in the Intensive Care Unit Error Producing Conditions in the Intensive Care Unit Frank A. Drews, PhD; Adrian Musters, BS; Matthew H. Samore, MD Abstract Up to 98,000 patients die because of human error in U.S. hospitals each year. Among the areas where errors occur frequently is t…

5635. Envisioning Patient Safety in the Year 2025: Eight Perspectives (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Henriksen_104.pdf
      January 01, 2025 - Envisioning Patient Safety in the Year 2025: Eight Perspectives Envisioning Patient Safety in the Year 2025: Eight Perspectives Kerm Henriksen, PhD; Caitlin Oppenheimer, MPH; Lucian L. Leape, MD; Kirk Hamilton, FAIA, FACHA, MS; David W. Bates, MD, MSc; Susan Sheridan, MBA; Mark E. Bruley, CCE; David M. Gaba, MD;…

5636. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
      April 02, 2008 - The Nature, Characteristics and Patterns of Perinatal Critical Events Teams The Nature, Characteristics and Patterns of Perinatal Critical Events Teams William Riley, PhD; Helen Hansen, PhD, RN; Ayse P. Gürses, PhD; Stanley Davis, MD; Kristi Miller, RN, MS; Reinhard Priester, JD Abstract The Institute …

5637. Appendix B. Clinical Materials to Share With Primary Care Providers (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apb2.html
      December 01, 2013 - Transitioning Newborns from NICU to Home Appendix B. Clinical Materials to Share With Primary Care Providers (continued) Previous Page Next Page Table of Contents Transitioning Newborns from NICU to Home A Resource Toolkit Basic Components of the Health Coach Program Family Information Packet …

5638. Chartbook on Person- and Family-Centered Care: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/nhqrdr/chartbooks/personcentered/pcc-slides.html
      June 01, 2018 - Chartbook on Person- and Family-Centered Care: Slide Presentation National Healthcare Quality and Disparities Report Slide 1 National Healthcare Quality and Disparities Report Chartbook on Person- and Family-Centered Care September 2016 Slide 2 National Healthcare Quality and Disparities Report …

5639. Final Progress Report: Malpractice Insurers’ Medical Error Surveillance and Prevention Study (MIMESPS) (pdf file)
      www.ahrq.gov/sites/default/files/2024-09/studdert-report.pdf
      January 01, 2024 - Final Progress Report: Malpractice Insurers’ Medical Error Surveillance and Prevention Study (MIMESPS) MALPRACTICE INSURERS’ MEDICAL ERROR SURVEILLANCE AND PREVENTION STUDY (MIMESPS) Principal Investigator: David M. Studdert, LLB, ScD Team Members: Harvard School of Public Health: Allison Nagy, BA Ann Louise Puo…

5640. Final Progress Report: Oral Chemotherapy Safety in Ambulatory Oncology: A Proactive Risk Assessment (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/weingart-report.pdf
      January 01, 2024 - Final Progress Report: Oral Chemotherapy Safety in Ambulatory Oncology: A Proactive Risk Assessment Final Progress Report 1.0 TITLE PAGE Oral Chemotherapy Safety in Ambulatory Oncology: A Proactive Risk Assessment Principal Investigator Saul N. Weingart, MD, PhD Co-Investigators Maureen Connor, RN, MPH Syl…