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www.ahrq.gov/sites/default/files/wysiwyg/policy/foia/foiamemo0309.pdf
March 19, 2009 - The Freedom of Information Act (FOIA) Memoradum
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f ROM: ",,~E AnORl\EY GEJ"ERAL
SUBJE~The Freedom QflnfQunatjQo Act (FOlA)
The Freedom of Information Act (FOlA), 5 U.S.c…
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/TK2_T4_Common_Suspected_Infections_Tools_To_Improve_Communication_and_Decisionmaking.docx
October 01, 2016 - Slide 7
Consequences
SAY:
The intent here is that, by now, there will be strong buy-in regarding the
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www.ahrq.gov/news/events/nac/2015-11-nac/nacmtg1115-minutes.html
May 01, 2016 - We need to understand multiple aspects, the effects of consultation time, and the downstream consequences … Researchers might study how overtesting can lead to unintended harmful diagnostic consequences.
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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 - more
widespread audience and a larger number of patient record extracts may reveal
unanticipated consequences … Some unintended
consequences of information technology in health
care: the nature of patient care information
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Campbell_94.pdf
March 30, 2008 - Survey
respondents also expressed fear of the consequences of being associated with an error. … Fear of punitive consequences for
individuals after they report an error is believed to be a strong
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.pdf
May 01, 2017 - • And C stands for consequences—
Consequences, in terms of established
team goals, should be stated
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www.ahrq.gov/sites/default/files/2024-12/cook-hoas-report.pdf
January 01, 2024 - order for system
change to occur: (1) shared recognition of unsafe practices; (2) belief that the
consequences … create real consequences for the nursing staff, administration, and pharmacy in
terms of their relationships … The change agents, in turn, require ongoing feedback about needs
and opportunities to experience the consequences
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www.ahrq.gov/sites/default/files/2024-02/jones-report.pdf
January 01, 2024 - Final Progress Report: Implementing a Program of Patient Safety in Small, Rural Hospitals
Implementing a Program of Patient Safety in Small,
Rural Hospitals
Principal Investigators
Katherine J. Jones, PhD, PT, January 2007 – June 20071
Keith J. Mueller, PhD, July 2005 – December 20061
Team Members
Anne Skinn…
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www.ahrq.gov/prevention/resources/vision/resources/vision1.html
October 01, 2002 - independence and disability reduced to standard scales, "to the neglect of the emotional and social consequences
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-insertion-notes.docx
April 01, 2022 - develop workarounds to overcome system barriers, but sometimes those workarounds can have unintended consequences
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/018-revision-summary-contact-precautions.docx
October 01, 2024 - in MRSA transmission after discontinuing contact precautions.14,15
· The potential for unintended consequences
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www.ahrq.gov/sites/default/files/2024-03/strom2-report.pdf
January 01, 2024 - capacity to lead to errors, difficulty in proper use (low
therapeutic ratio), and/or severity of the consequences … Unintended consequences of information
technologies in health care - an interactive sociotechnical … Unintended Consequences of Healthcare Information
Technology: Interactive Sociotechnical Analysis. … “Looking into and out of CPOE's Black Box: Monitoring its Uses, Benefits
and Consequences.”
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/12-identifying-stakeholders-facilitator.docx
June 01, 2023 - AHRQ Safety Program for Improving
Surgical Care and Recovery
Identifying Stakeholders: How To Do a Stakeholder Analysis for Your Improving Surgical Care and Recovery Program
Slide Title and Commentary
Slide Number and Slide
Identifying Stakeholders – Title Slide
Welcome to the presentation, “Identifying Stakeholde…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/new-sops-workplace-safety-zebrak.pdf
July 22, 2022 - Response
(Strongly Agree/Agree)
I can report my concerns about workplace safety without
fear of negative consequences
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu6.html
October 01, 2014 - Such unintended consequences of quality improvement are well recognized.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/communication/cahps-strategy-section-6-g.pdf
July 31, 2017 - affecting the patient’s experience
with health care, poor patient-physician
communication has important consequences
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www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu6.html
October 01, 2014 - Such unintended consequences of quality improvement are well recognized.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module3/empowerment-slides-spanish.pptx
January 01, 2014 - Nursing. 2008;34(3):26-35. http://www.commonwealthfund.org/Publications/In-the-Literature/2007/Nov/Consequences-of-Empowered-CNA-Teams-in-Nursing-Home-Settings
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-1-implementation-guide.pdf
January 01, 2018 - Million Hearts: Costs & Consequences.
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www.ahrq.gov/chsp/about-chsp/centers-of-excellence/rand.html
August 01, 2017 - RAND Center of Excellence
Overview
The Agency for Healthcare Research and Quality (AHRQ) funded the RAND Corporation, in collaboration with researchers from Pennsylvania State University, UCLA, and Harvard University, to create a Center of Excellence on Health System Performance. The Center's charter is to id…