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1. Using Patient Cases for Learning | Agency for Healthcare Research and Quality
   www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety4.html
   September 01, 2022 - Nurses in Diagnostic Safety: Pragmatic Recommendations for Nurse Leaders and Educators Using Patient Cases … in the Diagnostic Process Recognizing and Supporting Nurses in Diagnostic Safety Using Patient Cases … form of communication and can serve as a catalyst for safety and healthcare change. 41,42 Patient cases … Table 2 presents suggested steps for presenting and debriefing patient cases to enhance nurses’ learning … Several sources can be used to identify cases that illustrate nurses’ role in the diagnostic process,

2. Catheter-Associated Urinary Tract Infection (CAUTI) | Agency for Healthcare Research and Quality
   www.ahrq.gov/topics/catheter-associated-urinary-tract-infection-cauti.html
   January 01, 2013 - Most cases of CAUTI are preventable. … It found very few cases where payment was denied due to a CAUTI.

3. AHRQ WebM&M | Agency for Healthcare Research and Quality
   www.ahrq.gov/cpi/about/otherwebsites/webmm.ahrq.gov/index.html
   October 01, 2015 - anonymously by our readers and includes interactive learning modules on patient safety ("Spotlight Cases … WebM&M was recently added to AHRQ PSNET , and includes Cases and Commentaries as well as Perspectives … Go to http://psnet.ahrq.gov Products The site offers Cases and related Commentaries monthly, including … Audiences Depending on the depth of detail desired, the Cases, Commentaries, “Perspectives on Safety … Settings of Care AHRQ WebM&M accepts cases involving all settings of care (ambulatory or outpatient

4. Final Progress Report: Developing a Rational Clinical Approach to the Disposition of TIA Cases in the ED (pdf file)
   www.ahrq.gov/sites/default/files/2024-12/reeves-report.pdf
   January 01, 2024 - Final Progress Report: Developing a Rational Clinical Approach to the Disposition of TIA Cases in the … 1-year no cost extension) Title: Developing a Rational Clinical Approach to the Disposition of TIA Cases … with a score of 0 up to 12% in cases with a score of 6 or 7. … Although hospitalization may make sense for high risk TIA cases, it is clear that many TIA cases are … in the ED and how they believe TIA cases should be managed.

5. COVID-19 Nursing Home Data | Agency for Healthcare Research and Quality
   www.ahrq.gov/nursing-home/resources/covid-19-nursing-home-data.html
   May 01, 2022 - It includes a total of COVID-19 confirmed cases, suspected cases, and deaths. 

6. Final Progress Report: Diagnostic Error in Dystonia (pdf file)
   www.ahrq.gov/sites/default/files/2025-03/tanner-report.pdf
   January 01, 2025 - In 625 cases of primary dystonia and 6250 controls, utilization data show that cases had more medical … Of these cases, 520 incident dystonia cases were contacted regarding the diagnostic error survey; 218 … cases completed the survey. … Thirty-two (70%) cervical dystonia cases, 25 (66%) blepharospasm cases, 31 (61%) laryngeal dystonia … blepharospasm cases, and 41% (14/34) of limb dystonia cases.

7. Hospital-Level Gap Analysis for MRSA and SSI Prevention (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/132-gap-analysis-hospital-level.pdf
   April 01, 2025 - How are cases for SSIs associated with hip joint replacement detected? Check all that apply. …  Communication with patients via letters after discharge to identify cases  Other: 22. … How are cases for SSIs associated with spinal fusion detected? Check all that apply. … How are cases for SSIs associated with CABG with sternotomy detected? Check all that apply. … How are cases for SSIs associated with other types of surgery with sternotomy detected?

8. P-HIP Excel Tool Guidance (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/phip-mrabstraction-tool-guidance.pdf
   June 02, 2025 - Import a CSV file of cases to the current cases sheet. 3. … Data for all cases is saved as a CSV file. … to use all cases. 2 Earliest date. … Required if selecting cases by date. 4 View summary of selected cases on Score sheet. 5 View summary … and run chart of selected cases. 6 Use this column to indicate directly selected cases. 7 Discharge

9. Exhibit 20. Estimates of the total number of SSI cases in the United States, based on the rates used | Agency for Healthcare Research and Quality
   www.ahrq.gov/research/findings/final-reports/ssi/ssiexh20.html
   April 01, 2018 - Estimates of the total number of SSI cases in the United States, based on the rates used Previous … Only 2 facilities performed coronary artery bypass grafting, with a pooled of just under 5,000 SSI cases … Hernia repair, performed by 3 facilities, give a national estimate of 1,000 cases or less from pooled … hip replacement (all 4 facilities) give an estimated national incidence of slightly over 5,000 SSI cases … data from all 4 facilities for total knee replacement give a national estimate of very close to 5,000 cases

10. CRP Certification: Promoting Accountability and Learning After Adverse Events (pdf file)
    www.ahrq.gov/sites/default/files/2024-07/gallagher5-report.pdf
    January 01, 2024 - In Washington, 81% of the cases were certified by the review panel, and four certified cases that were … Seventy percent of the Washington cases involved severe harm, including nine death cases. … Two thirds of the cases involved severe harm, including two death cases. … CRP Certification Cases Reviewed in Washington and California, 2016-2020 Location Cases reviewed … to date Cases Certified Severe harm cases (temporary severe harm or higher) Cases closed by

11. Factors That Influence Effectiveness of Checklists | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-4.html
    September 01, 2020 - Checklists seem to help more in complex cases than in simple cases, 16 which is similar to studies on … as well. 18 Checklists may be more effective in difficult cases because there is more room for error … , 14 , 16 In such settings, potentially confounding factors such as case mix and complexity of the cases … Furthermore, studies in experimental settings often use complex cases, which reflect a different sample … Lastly, while in experimental studies participants are required to use the checklists on all cases they

12. Guide for Clinical Leaders: Calibrate Dx: A Resource To Improve Diagnostic Decisions (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/multiple/Calibrate-Dx-Clinical-Leaders-Guide.pdf
    September 01, 2022 - Calibrate Dx is a resource to help clinicians find and analyze cases in a structured way to gain insights … incorporate Calibrate Dx into their routine practice so they can consistently learn from different cases … Clinical leaders can model discussion of their own cases to bolster psychological safety. … � Help clinicians identify types of cases to review. … At the beginning, teams will often need help deciding which types of cases to review.

13. 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 - Identification of Cases and Controls For specific aim 1, cases were identified as depression patients … The event date for the cases was defined as the date of the first ever diagnosis of dementia. … Cases and controls were matched on age (±1 year) and sex. … With matching, the distribution of age and sex was similar across cases and controls. … For the cognition objective, cases were defined based on the MDS cognition scale.

14. AHRQ WebM&M—Online Medical Error Reporting and Analysis (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wachter.pdf
    March 11, 2005 - Cases will be of “near misses.” … Cases accompanied by detailed root cause analyses. … Online Error Reporting and Analysis 215 Cases.” … Just 1 percent of the cases came from the psychiatry field. … Adverse event/error types among published cases* Figure 1.

15. Final Progress Report: Unexpected Clinical Events: Impact on Patient Safety (pdf file)
    www.ahrq.gov/sites/default/files/2024-12/weinger2-report.pdf
    January 01, 2024 - Demographic attributes of videotaped cases Case Attributes No NRE Cases (n=265) NRE Cases (n=139) Sig … 19% (36/187) of NRE (8.9% of all cases). … , representing 10.6% of all cases. … Seven cases led to patient injury. … During 20 noncardiac cases and 15 cardiac cases, drug/fluid tasks comprised 8% of induction and 7% of

16. Debrief Example - Implementation Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-k.html
    May 01, 2017 - Where: Observed cases in the ambulatory surgery center (ASC). … Slide 5: Data Collection Baseline data collection period: 3/2/2015 – 3/6/2015 Number of cases … Case volume doesn’t allow sufficient time for a debrief between cases. … Smith’s cases Timeframe: Example: The week of 3/9/2015 – 3/13/2015 Slide 14 … Smith’s cases Timeframe:  Example: The week of 3/16/2015 – 3/20/2015 Slide

17. Improving Communication and Teamwork in the Surgical Environment
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-k-debrief.pptx
    June 01, 2015 - Framework 4 Data Collection Baseline data collection period: 3/2/2015 – 3/6/2015 Number of cases … Smith’s Cases 42065 42066 42067 42068 42069 0.5 0.75000000000000111 0.25 0.67000000000000115 0.5 … Smith’s cases Timeframe: Example: The week of 3/9/2015 – 3/13/2015   QI Study … Smith’s Cases 3/2/2015 3/3/2015 3/4/2015 3/5/2015 3/6/2015 3/9/2015 3/10/2015 3/11/2015 3/12/2015 3/ … Smith’s Cases 3/2/2015 3/3/2015 3/4/2015 3/5/2015 3/6/2015 3/9/2015 3/10/2015 3/11/2015 3/12/2015 3/

18. Final Progress Report: Utility of Predictive Systems in Diagnostic Errors (UPSIDE) (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/auerbach-report.pdf
    January 01, 2025 - We did this by carefully examining cases in medical centers connected to HOMERuN. … Reviewers then assessed cases in a randomized order, excluding patients whose cases were identified … on a minimum of 10 standard cases. … Only then did the teams proceed to adjudicate the study cases. … We addressed these concerns through training and inter-site over-read of cases.

19. CHIPRA 212 Tables 5 to 8 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-212-tables-5-8.pdf
    June 02, 2025 - (7.5) * Data summarize characteristics of the broader population residing in ZIP codes of sampled cases … 16.2) * Data summarize characteristics of the broader population residing in ZIP codes of sampled cases … $78,691 * Data summarize characteristics of the broader population residing in ZIP codes of sampled cases … 100 * Data summarize characteristics of the broader population residing in ZIP codes of sampled cases

20. The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
    March 27, 2008 - All of the Code 911 cases and 2 years of Code 912 cases were analyzed by at least one nurse and one … The most common wrong-side cases were herniorrhaphies (three cases). … Cases reported 2003 2004 2005 Code 911 9 21 22 Code 912 93a 104 98 a 2003 Code 912 cases were … Of the Code 912 cases analyzed, 68 (34 percent) were wrong-procedure cases, 51 (25 percent) were wrong … Complex cases had as many as 10 root causes.