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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
January 01, 2004 - to the point of service
• Design around precarious events/active failures:
• Operative/post-op complications … Advances in Patient Safety: Vol. 2
430
Active failures
Operative/postop complications/infections … mostly infants or seniors) die as a result of their infections.22
Moreover, operative and postoperative complications
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www.cpsi.ahrq.gov/ncepcr/research-transform-primary-care/transform/profile/berry.html
April 01, 2015 - Skip to main content
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/action-alliance/high-reliability-journey-slides.pptx
September 26, 2023 - VHA's Journey to High Reliability: Advancing Toward Zero Harm and Becoming a Learning Health System
September 26, 2023
Pre-Decisional Deliberative Document
Internal VA Use Only
Advancing Toward Zero Harm and
Becoming a Learning Health System
Gerard R. Cox, MD, MHA
Assistant Under Secretary for Health for Quality & …
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_3_Pres_video_508.pdf
May 30, 2013 - improve:
– Patient safety and quality
• Improved communication
• Decrease in hospital-acquired complications
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www.cpsi.ahrq.gov/teamstepps-program/curriculum/communication/tools/handoff.html
May 01, 2023 - Skip to main content
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www.cpsi.ahrq.gov/talkingquality/measures/measure-questions.html
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www.cpsi.ahrq.gov/news/blog/ahrqviews/high-quality-behavioral-healthcare.html
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www.cpsi.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/improving-fac-notes.html
May 01, 2017 - surgical teams who exhibit fewer teamwork behaviors put patients at higher risk for death and serious complications … Both complications and mortality from surgery decreased at nearly every site. … Additional studies listed here have all demonstrated similar decreases in complications and often in
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
October 01, 2018 - disparities over time:
• Deaths per 1,000 elective-surgery admissions having developed specified complications … White: Deaths per 1,000 elective-surgery admissions having
developed specified complications of care … Potential complications resulting from the
development of CAUTI include cystitis, pyelonephritis, endocarditis … rc
en
t
Teaching Nonteaching
• Importance: Colorectal procedures have high rates of postoperative complications … Nonadherence to evidence-based best practices is associated with an increased risk of these
complications
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www.cpsi.ahrq.gov/hai/pfp/hacrate2013-appendix.html
October 01, 2015 - Hospital-Acquired Antibiotic-Associated C. difficile
100,000
3.1
MPSMS (2013)
Mechanical Complications
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4i_pdi11-dehiscence-bestpractices.pdf
May 17, 2016 - Selected Best Practices and Suggestions for Improvement
Pediatric Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4i
Selected Best Practices and Suggestions for Improvement
PDI 11: Postoperative Wound Dehiscence
Why focus on postoperative wound dehiscence in…
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/overview/overview-facnotes.docx
May 01, 2017 - Module 1: Script and Slides
AHRQ Safety Program for Ambulatory Surgery
Management Practices for Sustainability
Module 1: Overview
AHRQ Safety Program for Reducing CAUTI in Hospitals
Facilitator Notes
SLIDE 1
Title: Management Practices for Sustainability, Module 1: Overview
SAY: This module was created by the Inst…
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www.cpsi.ahrq.gov/news/blog/ahrqviews/2022-national-healthcare-disparities-report.html
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www.cpsi.ahrq.gov/ncepcr/research-transform-primary-care/transform/profile/rittenhouse.html
October 01, 2015 - Skip to main content
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www.cpsi.ahrq.gov/ncepcr/reports/grants-impact/external.html
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-NHQDR-appendixes-ACDE-rev.pdf
January 01, 2023 - Taking the “hospital admissions for uncontrolled diabetes without complications per 100,000
population … 100,000 population, age 18 and over
HCUP 2020
Hospital admissions with diabetes with short-term complications … 100,000 population, age 18 and over
HCUP 2020
Hospital admissions with diabetes with short-term complications … per 100,000 population, ages 6-17
HCUP 2020
Hospital admissions with diabetes with long-term complications … per 100,000 population, ages 6-17
HCUP 2020
Hospital admissions with diabetes with long-term complications