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1521. Candor-Impguide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/candor-impguide.pdf
      April 01, 2016 - Purpose: The Communication and Optimal Resolution (CANDOR) Toolkit Implementation Guide is a reference for organizational leaders who are committed to improving their response to unexpected patient harm events. The guide describes the CANDOR process, implementation phases, resources, and responsibilities to support s…

1522. 3. What are the best practices in pressure ulcer prevention that we want to use? | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3.html
      October 01, 2014 - Preventing Pressure Ulcers in Hospitals 3. What are the best practices in pressure ulcer prevention that we want to use? Previous Page Next Page Table of Contents Preventing Pressure Ulcers in Hospitals Overview Key Subject Area Index 1. Are we ready for this change? 2. How will we manage ch…

1523. Final Progress Report: Mining complex clinical data for patient safety research (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/hripcsak-report.pdf
      January 01, 2024 - Final Progress Report: Mining complex clinical data for patient safety research Principal Investigator: Hripcsak, George Progress Report Close-Out Documentation Title: Mining complex clinical data for patient safety research Principal Investigator and Senior Team Members: George Hripcsak, MD, MS (PI) Caro…

1524. Learn About CUSP, Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/modules/learn/fac-cusp.html
      December 01, 2012 - Learn About CUSP, Facilitator Notes CUSP Toolkit The Learn about CUSP module of the CUSP Toolkit offers an outline and brief history of the CUSP model, summarizes the CUSP Toolkit modules, and how to use them. Contents Slide 1. Cover Slide Slide 2. Learning Objectives Slide 3. CUSP Supports Kotter's…

1525. 3. What are the best practices in pressure ulcer prevention that we want to use? | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3.html
      October 01, 2014 - Preventing Pressure Ulcers in Hospitals 3. What are the best practices in pressure ulcer prevention that we want to use? Previous Page Next Page Table of Contents Preventing Pressure Ulcers in Hospitals Overview Key Subject Area Index 1. Are we ready for this change? 2. How will we manage ch…

1526. Chapter 3. Designing and Testing Methods to Stratify Risk of Surgical Site Infections | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ssi/ssi3.html
      April 01, 2018 - Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection Chapter 3. Designing and Testing Methods to Stratify Risk of Surgical Site Infections Previous Page Next Page Table of Contents Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome …

1527. Advances in Patient Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/advances/index.html
      July 01, 2022 - Advances in Patient Safety Next Page Table of Contents Advances in Patient Safety Acknowledgments Preface Peer Reviewers for Volume 1. Research Findings Peer Reviewers for Volume 2. Concepts and Methodology Peer Reviewers for Volume 3. Implementation Issues Peer Reviewers for Volume 4. Pro…

1528. NPSD Data Spotlight - Falls: Associated Factors and Clinical Outcomes (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-falls-rev.pdf
      March 01, 2023 - NPSD Data Spotlight - Falls: Associated Factors and Clinical Outcomes Falls: Associated Factors and Clinical Outcomes NPSD Data Spotlight This document is in the public domain and may be used and reprinted without permission. Citation of the source is appreciated. Suggested citation: NPSD Data Spotlight, Falls…

1529. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/match.pdf
      August 01, 2012 - preventable ADE was $4,800 per event, based on a 1997 study done by Bates et al.7 Some organizations have calculated

1530. Improving Healthcare Safety by Enhancing Care Coordination (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-care-coordination.pdf
      June 30, 2025 - Improving Healthcare Safety by Enhancing Care Coordination AHRQ-Funded Patient Safety Project Highlights Improving Healthcare Safety by Enhancing Care Coordination Overview Care coordination is defined as the process of organizing patient care activities and sharing information among all individuals concerned wi…

1531. Slide 1
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/carecoordination/qdr2015-chartbook-carecoordination.pptx
      June 16, 2016 - The risk-standardized readmission rate is calculated as the number of “predicted” readmissions divided … The risk-standardized readmission rate is calculated as the number of “predicted” readmissions divided

1532. Making Healthcare Safer Practices: 13. Alarm Fatigue (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/alarm-fatigue-1.pdf
      March 01, 2020 - Alsaad et al. calculated changes in cost (measured in dollars) for patients who were originally monitored … Significant increase when alarms per patient day were calculated.

1533. TeamSTEPPS for Improving Diagnosis Facilitator's Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-facilitators-guide.pdf
      February 04, 2022 - TeamSTEPPS for Improving Diagnosis Facilitator's Guide TeamSTEPPS® for Diagnosis Improvement Facilitator’s Guide This page is intentionally blank. Contents Introduction: TeamSTEPPS for Diagnosis Improvement ........................................................1 TeamSTEPPS for Diagnosis Improvement Course …

1534. Mod5-Comm-Assessment (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-comm-assessment.pdf
      April 01, 2016 - Purpose: To help you identify members of your organization who are effective at delivering disclosure communications. Who should use this tool? Communication and Optimal Resolution (CANDOR) Implementation Team, Disclosure Lead(s), Disclosure Communicators. How to use this tool: Use the Communication Assessment Guid…

1535. How did CHIPRA quality demonstration States employ learning collaboratives to improve children's health quality? Evaluation Highlight #13 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight13.pdf
      September 08, 2015 - How did CHIPRA quality demonstration States employ learning collaboratives to improve children's health quality? Evaluation Highlight #13 The CHIPRA Quality Demonstration Grant Program In February 2010, the Centers for Medicare & Medicaid Services (CMS) awarded 10 grants, funding 18 States, to improve the qualit…

1536. Surgical Complication Prevention Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/guide-surgcomp.pdf
      December 01, 2017 - Surgical Complication Prevention Guide AHRQ Safety Program for Surgery Surgical Complication Prevention Guide AHRQ Publication No. 16(18)-0004-13-EF December 2017 AHRQ Safety Program for Surgery Surgical Complication Prevention Guide Contents Introduction .................................................…

1537. Final Progress Report: A Memory-Based Approach to Reducing Medication Errors (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/kazi-report.pdf
      January 01, 2024 - Final Progress Report: A Memory-Based Approach to Reducing Medication Errors A Memory-Based Approach to Reducing Medication Errors Project Final Report June 26th, 2023 Principal Investigator: Sadaf Kazi, PhD Team Members: Raj Ratwani, PhD Ella Franklin, MSN, RN Deanna-Nicole Busog Organization: MedSta…

1538. III. Intervention Steps and Tools | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/crctoolkit/crctoolkit3.html
      April 01, 2018 - Tracking and Improving Screening for Colorectal Cancer Intervention III. Intervention Steps and Tools Previous Page Next Page Table of Contents Tracking and Improving Screening for Colorectal Cancer Intervention I. Introduction II. Background III. Intervention Steps and Tools IV. References …

1539. Chapter 2. ST-PRA Development | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/stpra/stpra2.html
      April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers Chapter 2. ST-PRA Development Previous Page Next Page Table of Contents Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers Executive Summary Chapter 1. Introduction Chapter 2. ST-…

1540. Appendix A. Literature Review | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/stpra/stpraapa.html
      April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers Appendix A. Literature Review Previous Page Next Page Table of Contents Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers Executive Summary Chapter 1. Introduction Chapter 2. ST-…