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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
December 01, 2017 - The simple and inexpensive solution improved the working conditions and immediately doubled attendance
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www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
December 01, 2017 - The simple and inexpensive solution improved the working conditions and immediately doubled attendance
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_1-introduction.pptx
July 01, 2023 - teams to adapt and implement a series of action steps (patient safety bundles) on high-risk maternal conditions
-
www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/public-action-alliance-slides-040323_LOCKED.pdf
May 25, 2023 - myocardial infarction,
► heart failure
► pneumonia
► major surgical procedures
But not for:
► All other conditions
-
www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/CMS-Aug-23-board-session.pdf
August 22, 2023 - the most vulnerable, are provided effective care by evaluating variations in
care outcomes for key conditions
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/ASB-UTI-facilitator-guide.pdf
November 01, 2019 - elderly; thus, it can be difficult to understand if there is
a causal relationship between these two conditions
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
June 01, 2023 - historically marginalized populations: those who are economically disadvantaged, those with stigmatized health conditions
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docx
April 01, 2025 - messages are important to share with the team:
See the system, see the risks—the teams’ insights into conditions
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Chan.pdf
January 01, 2004 - Second,
the actions of the ATHENA DSS program, including unanticipated error
conditions known as “exceptions
-
www.ahrq.gov/sites/default/files/2025-02/auerbach-report.pdf
January 01, 2025 - evolution of clinical scenarios or the absence of a gold
standard diagnostic test for many inpatient conditions
-
www.ahrq.gov/news/events/nac/2022-11-nac/nacmtg111722-minutes.html
July 01, 2023 - The members also stressed the importance of addressing multiple chronic conditions.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
May 01, 2003 - These conditions can be ameliorated if physicians in
training, as future team leaders, facilitate communication
-
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 - specific and direct causal relationship), as
well as multiple contributing factors (e.g., “environmental conditions
-
www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/final-rapid-cycle-research-guidance.pdf
June 01, 2015 - tested solution to be scaled up, disseminated, or continued outside of the
experimental time frame and conditions … Design the system for normal conditions before considering what to do about exceptional
cases.
6. … Diaz45 notes that using SPC is preferred to conducting a RCT under some conditions
because it may be … whether the study
patients were a small sub group (e.g., they had heart disease but no other chronic
conditions
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/43-pathway-worksheet.docx
June 01, 2023 - Improving Surgical Care and Recovery Core and Surgery Specific Pathways Worksheet
Use this worksheet to develop enhanced recovery pathways for use at your hospital. The information in this tool is based on evidence reviews (see appendix) conducted by the National Project Team at the American College of Surgeons and Jo…
-
www.ahrq.gov/sites/default/files/2024-01/gallagher2-report.pdf
January 01, 2024 - Final Progress Report: Using Team Simulation to Improve Error Disclosure to Patients and Safety Culture
AHRQ Grant Final Progress Report
Title of Project: Using Team Simulation to Improve Error Disclosure to Patients and Safety
Culture
Principal Investigator: Thomas H. Gallagher, MD
Co-Investigators: Sarah Shann…
-
www.ahrq.gov/sites/default/files/wysiwyg/lhs/lhs_case_studies_bsw.pdf
April 01, 2019 - Baylor Scott & White Health: Building a Foundation for Continuous Improvement
Baylor Scott & White Health: Building a Foundation for
Continuous Improvement
The Agency for Healthcare Research and Quality (AHRQ) has developed a series of case studies
to help health system chief executive officers and other C-sui…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.pdf
June 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time
Pressure Ulcer Healing
On-Time Pressure Ulcer Assessment
The On-Time Pressure Ulcer Assessment incorporates elements from the Bates-Jensen Wound Assessment
Tool (BWAT) with additional standardized treatment and intervention descriptors. The On-Time Pressure
Ulc…
-
www.ahrq.gov/hai/tools/mvp/modules/cusp/overview-cusp-mvp-facguide.html
February 01, 2017 - Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients: Facilitator Guide
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients
Say: …
-
www.ahrq.gov/sites/default/files/publications2/files/dx-issue-brief-20-brazil-health-system.pdf
August 01, 2024 - Learning from AHRQ's Diagnostic Safety Culture Survey at a Tertiary Care Health System in Brazil: A Case Study
PATIENT
SAFETY
e
Issue Brief 20
Learning from AHRQs’ Diagnostic Safety
Culture Survey at a Tertiary Care Health
System in Brazil: A Case Study
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e
Issue Brief 2…