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2861. Selected Best Practices and Suggestions for Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4l_combo_psi15-accidentalpuncturelaceration-bestpractices.pdf
      May 31, 2016 - Selected Best Practices and Suggestions for Improvement Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety 1 Tool D.4l Selected Best Practices and Suggestions for Improvement PSI 15: Accidental Puncture or Laceration Why Focus on Accidental Puncture and Laceration? • A…

2862. Engineering High Reliability Learning Lab (EHRLL) | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/resources/learning-lab/ehrll-long-desc.html
      April 01, 2022 - Engineering High Reliability Learning Lab (EHRLL) Principal Investigator:  Sara Singer, Ph.D., Harvard University, Cambridge, MA AHRQ Grant No.:  HS24453 Project Period:  09/30/15–09/29/21 Description:  The goal of this learning lab was to enhance capacity for innovation and develop highly reliable system…

2863. Acute Care Learning Laboratory—Reducing Threats to Diagnostic Fidelity in Critical Illness | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/resources/learning-lab/acute-care-threats-long-desc.html
      February 01, 2024 - Acute Care Learning Laboratory—Reducing Threats to Diagnostic Fidelity in Critical Illness Principal Investigator: Brian Pickering, M.B., B.Ch., M.Sc., Mayo Clinic, Rochester, MN AHRQ Grant No.: HS26609 Project Period: 09/30/18-11/30/22 Description: The overall goal of this learning lab was to reduce …

2864. 025-Ss-Why-Choose-Cusp-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/025-ss-why-choose-cusp-fg.docx
      April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI Why Choose a CUSP Approach? Surgical Services Slide Title and Commentary Slide Number and Slide Why Choose a CUSP Approach? SAY: Welcome to this presentation titled “Why Choose a CUSP Approach?” CUSP is short for the “Comprehensive Unit-based Safety Program.” …

2865. Health Care Simulation to Advance Safety: AHRQ Issue Brief (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/simulation-brief.pdf
      February 01, 2015 - Health Care Simulation to Advance Safety: AHRQ Issue Brief Foreword Simulation has long been recognized for the integral role it plays in high- risk industries. Our aerospace, transportation, and power-generation industries have become steadily safer over the years with the aid of simulation. As the Ebola virus di…

2866. Communication of Weight Classification for Children Who Are Overweight or Obese (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-241-bmi-communication-full-report.pdf
      February 01, 2020 - disparities regarding excess weight between ethnic groups must look beyond income and education to consider

2867. Final Progress Report: Engineering Highly Reliable Communication and Coordination Systems for High-Risk Patients, Referrals, and Tests (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/singer-benneyan-phillips-report.pdf
      January 01, 2025 - process, teams must make opportunities to reflect in order to internalize their learning, and they must consider

2868. 029-Ss-Review-Ssi-Prevention-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/029-ss-review-ssi-prevention-fg.docx
      April 01, 2025 - Teams may consider tailoring the tool to focus on surgical site infections (SSIs) by adding or modifying

2869. CHIPRA 194: Overuse of Imaging for the Evaluation of Children With Primary Headache Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-194-fullreport.pdf
      April 01, 2019 - CHIPRA 194: Overuse of Imaging for the Evaluation of Children With Primary Headache Report 1 Overuse of Imaging for the Evaluation of Children with Primary Headache Section 1. Basic Measure Information 1.A. Measure Name Overuse of Imaging for the Evaluation of Children with Primary Headache 1.B. Measure Numbe…

2870. Final Progress Report: Improving Medication Safety Across Clinical Settings (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/bates-report.pdf
      January 01, 2024 - Final Progress Report: Improving Medication Safety Across Clinical Settings FINAL REPORT: November 29, 2007 Improving Medication Safety Across Clinical Settings Principal Investigator: David W. Bates; dbates@…

2871. Development and Usability Testing of the Agency for Healthcare Research and Quality Common Formats to Capture Diagnostic Safety Events (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/development-and-usability-testing-common-formats.pdf
      January 01, 2022 - Development and Usability Testing of the Agency for Healthcare Research and Quality Common Formats to Capture Diagnostic Safety Events ORIGINAL ARTICLE Development and Usability Testing of the Agency for Healthcare Research and Quality Common Formats to Capture Diagnostic Safety Events Andrea Bradford, PhD,*† U…

2872. Voluntary Adverse Event Reporting in Rural Hospitals (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Schade_63.pdf
      January 01, 2007 - Voluntary Adverse Event Reporting in Rural Hospitals Voluntary Adverse Event Reporting in Rural Hospitals Charles P. Schade, MD, MPH; Patricia Ruddick, MSN, APRN-BC; David R. Lomely, BS; Gail Bellamy, PhD Abstract Since 2004, we have managed a voluntary Web-based medical adverse event (AE) reporting system …

2873. Designing the Built Environment for A Culture and System of Patient Safety – A Conceptual, New Design Process (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Dickerman_84.pdf
      June 04, 2008 - For example, consider lighting.

2874. Improving Patient Safety Using ATHENA-Decision Support System Technology: The Opioid Therapy for Chronic Pain Experience (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Michel_92.pdf
      April 30, 2008 - Consider referral to addiction specialist to manage pain.”

2875. Appendix F. CAUTI Prevention in Long-Term Care: Frequently Asked Questions | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/prevent/clinical-faqs.html
      March 01, 2017 - Consider changing the container with the same frequency as changing bedpans and urinals.

2876. BLADDER SCAN – POLICY #2202 12/11/06 (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/prevent/clinical-faqs.docx
      March 01, 2017 - . · Consider changing the container with the same frequency as changing bedpans and urinals. · Use appropriate

2877. Final Progress Report: Developing and Training Interruption Management Strategies for Emergency Physicians (pdf file)
      www.ahrq.gov/sites/default/files/2024-09/ratwani-report.pdf
      January 01, 2024 - developed a general framework for expressing the cognitive strategies that emergency physicians should consider

2878. The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception Toward Co-Design (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/dx-safety-issue-brief-co-design-rev.pdf
      September 01, 2024 - patient the time needed to share all characteristics of their symptoms and for clinicians to fully consider

2879. The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception Toward Co-Design (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dx-safety-patient-role.pdf
      September 01, 2024 - patient the time needed to share all characteristics of their symptoms and for clinicians to fully consider

2880. Final Progress Report: Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/bundy-report.pdf
      January 01, 2024 - aviation industry’s examination of “near-miss” events, the medical and pharmaceutical industries should consider