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3201. Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/diagnostic-safety-transitions-care.pdf
      June 01, 2023 - Cognitive errors can include: ■ Faulty hypothesis generation (such as failing to consider rare diseases

3202. Continuity of Insurance: Coverage Presumed Ineligible (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/duration/chipra-155-fullreport.pdf
      September 01, 2018 - assumptions used in Coverage PE and Coverage PI tend to form upper and lower bounds on what we may consider

3203. Final Progress Report: Understanding the implementation of new practices in healthcare organizations (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/nembhard-report.pdf
      January 01, 2024 - In selecting strategies, leaders should consider the challenge as challenges can require different strategies

3204. Webinar Transcript: Better Care, Healthier People and Communities, More Affordable Care: 5 Years of the National Quality Strategy | Agency for Healthcare Research and Quality
      www.ahrq.gov/workingforquality/events/webinar-better-care-healthier-communities.html
      November 01, 2016 - 31] Heather Plochman:  We have some questions up on the slide here for you to take a look at and consider

3205. Final progress report: Developing Evidence for Safety Surveillance from Device Adverse Event Reports (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/mao-report.pdf
      January 01, 2025 - Final progress report: Developing Evidence for Safety Surveillance from Device Adverse Event Reports Final progress report Developing Evidence for Safety Surveillance from Device Adverse Event Reports Grant number: 1R03HS026291-01 Supported by AGENCY FOR HEALTHCARE RESEARCH AND QUALITY Research Team Principal invest…

3206. Final Progress Report: Evaluating and Improving Present-On-Admission for Performance Reporting (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/goldman-report.pdf
      January 01, 2025 - Final Progress Report: Evaluating and Improving Present-On-Admission for Performance Reporting Evaluating and Improving Present-On-Admission for Performance Reporting L. E lizabeth Goldman, MD, MCR, Principal Investigator Andrew Bindman, MD, Peter Bacchetti, PhD, Co-Investigators University of California, San …

3207. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevhosp-reports-slides.pptx
      November 30, 2013 - PowerPoint Presentation AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and ED Visits Training Introduction to Preventable Hospital and ED Visits Reports Preventable Hospital and ED Visits Electronic Reports Electronic Reports Transfer Risk Report – High Risk Transfer Risk Report – Medium Ris…

3208. 2025 AHRQ Surveys on Patient Safety Culture® (SOPS®) Nursing Home Survey Version 2.0 Pilot Test Results (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2025-nursing-home-20-pilot-test-results.pdf
      January 01, 2025 - 2025 AHRQ Surveys on Patient Safety Culture® (SOPS®) Nursing Home Survey Version 2.0 Pilot Test Results 2025 AHRQ Surveys on Patient Safety Culture® (SOPS®) Nursing Home Survey Version 2.0 Pilot Test Results Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services …

3209. Usability Testing and the Relation of Clinical Information Systems to Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Rogers.pdf
      January 01, 2003 - Usability Testing and the Relation of Clinical Information Systems to Patient Safety 365 Usability Testing and the Relation of Clinical Information Systems to Patient Safety Michelle L. Rogers, Emily Patterson, Roger Chapman, Marta Render Abstract Background: The success of clinical information systems depend…

3210. Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care (pdf file)
      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 - Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care 369 Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care Patrick J. O’Connor, JoAnn M. Sperl-Hillen, Paul E. Johnson, William A. Rush Abstract Objectives: Diabetes-related medic…

3211. Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Baker_107.pdf
      March 30, 2008 - Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems Donald K. Baker, PharmD; James M. Hoffman, PharmD; Gregory A. Hal…

3212. CHIPRA 81: Pediatric Global Health-7 Measure Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-081-fullreport.pdf
      April 01, 2019 - Furthermore, there has been a general failure to consider positive child health outcomes that are essential

3213. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-erepguide_slides.pptx
      November 01, 2016 - PowerPoint Presentation AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing Facilitator Training Introduction to Pressure Ulcer Healing Reports 1 Electronic Reports Existing Pressure Ulcers Report Pressure Ulcers at Risk for Delayed Healing Weekly Wound Rounds Report Weekly Pressure Ulcer Treat…

3214. TeamSTEPPS Pocket Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/teamstepps-pocket-guide.pdf
      May 01, 2023 - TeamSTEPPS Pocket Guide Pocket Guide Team Strategies & Tools to Enhance Performance and Patient Safety Table of Contents TeamSTEPPS® ................................................. 1 Framework and Competencies ........................1 Key Skills .........................................................…

3215. Final Progress Report: Nurse Staffing Policy, Hospital Occupancy, Market Structure, and Patient Outcomes (pdf file)
      www.ahrq.gov/sites/default/files/2024-10/mchugh-report.pdf
      January 01, 2024 - Final Progress Report: Nurse Staffing Policy, Hospital Occupancy, Market Structure, and Patient Outcomes Final Progress Report Title: Nurse Staffing Policy, Hospital Occupancy, Market Structure, and Patient Outcomes Principal Investigator: Matthew D. McHugh Team Members: Linda H. Aiken (primary mentor); Jeffrey H.…

3216. Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/liability/brock.html
      August 01, 2017 - Advances in Patient Safety and Medical Liability Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative Previous Page Next Page Table of Contents Advances in Patient Safety and Medical Liability Preface Acknowledgments Prologue Silence A Commentary Reforming th…

3217. Final Progress Report: Developing a Framework to Study and Improve Communication to Enhance Diagnostic Quality in the ED (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/mahajan-manojlovich-report.pdf
      January 01, 2025 - A concluding group session asked participants to consider ways that communication contributes specifically

3218. AHRQ Safety Program for MRSA Prevention
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/046-evidence-behind-decolonization-strategies-slides.pptx
      October 01, 2024 - AHRQ Safety Program for MRSA Prevention AHRQ Safety Program for MRSA Prevention The Evidence Behind Decolonization Strategies for MRSA ICU & Non-ICU AHRQ Pub. No. 25-0007 October 2024 AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU The Evidence Behind Decolonization 1 Educational Objectives Discuss the imp…

3219. Final Progress Report: Detection, Education, Research, and Decolonization without Isolation in Long-term Care (DERAIL MRSA) (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/peterson-report.pdf
      January 01, 2025 - Final Progress Report: Detection, Education, Research, and Decolonization without Isolation in Long-term Care (DERAIL MRSA) Title: Detection, Education, Research, and Decolonization without Isolation in Long-term Care (DERAIL MRSA) Principal Investigator: Lance R. Peterson, MD Team Members: Ari Robicsek, MD, Jenni…

3220. Final Progress Report: Implementing Reduced Work Hours for All House Staff To Improve Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/landrigan2-report.pdf
      January 01, 2024 - detail the physiologic determinants of alertness and performance and the practical issues necessary to consider