-
www.ahrq.gov/sites/default/files/2024-02/miller-birkmeyer-report.pdf
January 01, 2024 - is, care provided by general and/or subspecialty
surgeons—represents a major component of specialty … In addition to wide
variation in clinical outcomes, recent evidence suggests that price- and case-mix … differences were
statistically significant, they were very small in magnitude and therefore of unclear
clinical … significant variability among the IDS with respect to
organizational structure, degree of financial and clinical … In reality, it seems unlikely that ACOs or other payment reforms aimed at improving
care coordination
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-probabilistic-thinking.pdf
September 01, 2022 - Although central to clinical practice, these topics are not emphasized as critical skills or typically … a patient to toxic substances,
inconvenience, or unnecessary care for which harms outweigh benefits. … , and it would not add substantial time or cognitive load to
clinical encounters. … care. … Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine;
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/health-literacy-pfe-070913.ppt
July 01, 2013 - Part I: Health Literacy
Objectives:
Define Health Literacy and Its Implications for Patient Care … Why is it important that I follow this plan? … Engage Patients
and Families1 (continued)
Help the patient and family understand the diagnosis, condition … because they are afraid of soiling linens or incontinence or fall risk:
*
“Men can use an external catheter … Bethesda, MD: Institute for Family-Centered Care, June 2006.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Ehringer_17.pdf
February 08, 2008 - We offer ideas about applying
elements and concepts of computerized clinical decision-support systems … In other words, the physician writes or creates orders for a
specific procedure, diagnosis, care, or … Patient education Stroke or CHF education booklets, diet education, diabetes care,
ostomy training. … once.”)12
Medication safety also includes alerts and reminders as appropriate to the patient’s condition … care.
-
www.ahrq.gov/sites/default/files/2024-01/nembhard-report.pdf
January 01, 2024 - associations, care networks, improvement experts, and government
agencies have launched or sponsored … implementation
strategy, and quality improvement, completed in collaborations per Career Development Plan … The relationship between voice climate and
timeliness of care in primary care clinics. … Microsystems in health care: Part 1. Learning from high-
performing front-line clinical units. … Prehospital 12-lead ECG: efficacy
or effectiveness? Prehosp Emerg Care 2006;10:374-7.
44.
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www.ahrq.gov/sites/default/files/2025-03/rinke-report.pdf
January 01, 2025 - Scope: Primary care pediatric practices
Methods: During a cluster-randomized clinical trial, practices … Appropriate actions included any of the
following: a) rechecking the BP, b) noting a plan to recheck … their BP rechecked in the intervention
phase versus 75% in the control phase (p<0.001); 27% had a plan … Clinical Trials. 2019. Feb 5. [Epub
ahead of print]
4. … Improved clinical outcomes for fee-for-
service physician practices participating in a diabetes care
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/OConnor.pdf
November 29, 2004 - These observed patterns of medical error define
specific clinical domains and patient subgroups for … these physicians provide regular care to 10 or more adults with diabetes. … rapidly lead to adverse clinical events. … Improving diabetes care in a large health care system:
an enhanced primary care approach. … Demographic and clinical characteristics of the 4,152 study subjects
Table 2.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/cauti-sustainability.pptx
December 01, 2015 - Maintaining a process by reassessing and making it current
24
24
PDSA Cycles Must Be:
Active
Quickly plan … Nurses (34)
Team Design
50
Physician Champion
Infection Prevention
Frontline staff/Champions
Clinical … measures of success
Safety Culture
84
Continue to assess safety culture annually
Evaluate the action plan … Four blank white speech bubbles
Plan … - Plan to carry out
the cycle
(who, what, where, when)
- Carry out the plan
- Document problems
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www.ahrq.gov/sites/default/files/wysiwyg/sops/databases/hospital/2024-hospital-workplace-safety-report-appendix.pdf
January 01, 2024 - Care
Aide/
Nursing
Asst. … Care
Aide/
Nursing
Asst. … Care
Aide/
Nursing
Asst. … Care
Aide/
Nursing
Asst. … Care
Aide/
Nursing
Asst.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Bernard.pdf
January 01, 2004 - The
algorithm flags patient safety events based on the International Classification of
Disease, Clinical … empirical analyses of the
precision and reliability of the candidate PSIs; and (3) reviews from 11 clinical … The clinical panels, in
particular, found that 5 of the 14 indicators could themselves be described … Xiht is a vector of controls for the demographic and clinical characteristics of
patient i, at hospital … from higher
quality hospitals and/or physicians).
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_1-introduction-speaker-notes.pdf
July 01, 2023 - Technical Elements Adaptive Elements
• Clinical knowledge • Culture
• Clinical expertise • Teamwork … While these technical elements are essential, there is a second side to care that
complements clinical … Imagine how the care you provide might be or feel different when you’re
completely in sync with your … These two interventions are: an obstetric hemorrhage emergency management plan
and support for patients … Williams, we may need to give you
blood products or move you to the OR if the
bleeding continues.
-
www.ahrq.gov/sites/default/files/2025-02/woods2-report.pdf
January 01, 2025 - process or context
• Missing information
• Lack of feedback in medical care systems
Assessment … The medical care provided during a
resuscitation is determined not only by the clinical situation but … Lack of standards and inconsistent formats for clinical communication of necessary
clinical information … of mechanisms of systems for verification of task completion or the stage of
completion of clinical … for a
particular type of medical care, such as emergency medical care or cancer treatment.
17
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/booklets/hip-fracture-booklet.pdf
November 01, 2023 - This booklet will help you:
■ Plan for recovery in the hospital
■ Plan for recovery at home
Near … If a decision needs to be made about your care
during surgery or if you cannot speak for yourself after … This helps us create
the best pain management plan for you. … So, even with home care, you or a family member may need to
change some bandages. … Nursing Home, Rehab, or Home Care
Recovery at Home
Taking Care of Your Surgical Wound
Showering
-
www.ahrq.gov/sites/default/files/2024-11/sarkar2-report.pdf
January 01, 2024 - systems to identify and address them in clinical practice, has not been defined. … validity or feasibility score for specific
measures. … In the future, we plan to collect the remaining years of patient safety measurement data and
evaluate … Development of clinical pharmacy key performance indicators for hospital
pharmacists using a … Framework for Conducting a Root Cause Analysis and Action Plan.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/introduction/scientific-rationale.pdf
March 01, 2022 - standardize HAI surveillance.4 In response, HHS spearheaded the development of
the first National Action Plan … accreditation,5 and the Centers for Medicare & Medicaid Services (CMS) outlined and
implemented a multiyear plan … No difference in MRSA/VRE
clinical cultures or bloodstream
infection in overall non-ICU
population … Routine contact
precautions continued to occur for known MRSA carriers by history or clinical cultures … Chlorhexidine – pharmacology and clinical application. Anaesth
Intensive Care. 2008;36(4):502-12.
-
www.ahrq.gov/sites/default/files/2025-02/poghosyan-report.pdf
January 01, 2025 - occur as or more frequently in primary care as in inpatient settings4 but are not well studied or … or follow up. … ,”22-25 “tasks left undone,”26,27 or “missed care”21,28-31 and can occur because of
time pressures, … treatment plan (e.g., “Follow up if the patient completed the
referral”); 3) Emotional Health Support … is delivered to patients.44 Thus, ECOS holds the potential to provide evidence to improve
clinical
-
www.ahrq.gov/sites/default/files/2024-03/bruzzese2-report.pdf
January 01, 2024 - Bruzzese
Center for Excellence in Health Care Journalism
4/21/2010‐8/20/2010
Karen Migdail
Agency … (4.4) “How likely are you to use ideas or topics presented at the
conference for future stories?” … Care Journalism presented Health Journalism 2010, AHCJ’s
annual conference. … Prepared by Leonard J Bruzzese 573.884.5606 bruzzesel@missouri.edu 4
Press briefing or spotlight … List of Publications and Products
Stories written about the conference or with information collected
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Hoff.pdf
January 01, 2003 - step or decision) rather than judgmental (i.e., the wrong plan of
action or decision taken for a patient … Thirteen of the 16 (81 percent)
involved errors of judgment, (i.e., an inappropriate or incorrect plan … inappropriate plan of action for a
patient’s care) and resulted in the residents’ failure to do something … not associated with shortcomings in resident clinical knowledge or technical
acumen. … that redistribute
the clinical work to other health care personnel, so that residents and attending
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2025_nursing_home_wps_ptII.pdf
January 01, 2025 - that staff are never or rarely rude to other staff compared to staff in
Memory Care Units (Item WPD1 … (Item WPB1)
93% 90% 85%
Equipment and assistive devices are in good working condition when
needed … (Item WPB1)
86% 90%
Equipment and assistive devices are in good working condition when needed to … (Item WPB1) 70% 84% 92%
Equipment and assistive devices are in good working condition
when needed … Aide/Nursing Assisstant
• Physician/Other Provider: Advanced Practice Nurse (Nurse Practitioner, Clinical
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2025-nursing-home-workplace-safety-report-appendixes.pdf
January 01, 2025 - that staff are never or rarely rude to other staff compared to staff in
Memory Care Units (Item WPD1 … (Item WPB1)
93% 90% 85%
Equipment and assistive devices are in good working condition when
needed … (Item WPB1)
86% 90%
Equipment and assistive devices are in good working condition when needed to … (Item WPB1) 70% 84% 92%
Equipment and assistive devices are in good working condition
when needed … Aide/Nursing Assisstant
• Physician/Other Provider: Advanced Practice Nurse (Nurse Practitioner, Clinical