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3601. What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdf
      January 01, 2003 - What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare 423 What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare William E. Encinosa, Fred J. Hellinger Abstract Objective: To estimate the impact of potentially preventable adverse event…

3602. 2022 National Healthcare Quality and Disparities Report Detailed Methods for Medical Expenditure Panel Survey Tables (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023qdr-meps-methods.pdf
      December 01, 2023 - 2022 National Healthcare Quality and Disparities Report Detailed Methods for Medical Expenditure Panel Survey Tables 2023 National Healthcare Quality and Disparities Report Detailed Methods for Medical Expenditure Panel Survey Tables U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research…

3603. Final Progress Report: Patient Safety Learning Laboratory to Enhance the Value and Safety of Neonatal Interfacility Transfers in a Regional Care Network (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/umoren-report.pdf
      January 01, 2025 - Final Progress Report: Patient Safety Learning Laboratory to Enhance the Value and Safety of Neonatal Interfacility Transfers in a Regional Care Network Patient Safety Learning Laboratory to Enhance the Value and Safety of Neonatal Interfacility Transfers in a Regional Care Network Rachel A. Umoren, MBBCh, MS Mega…

3604. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
      June 30, 2004 - Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative 133 Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative Daniel M. Harris, John M. Westfall, Douglas H. Fernald, Christine W. Duclos, David R. West, Linda Niebauer, Linda Ma…

3605. Work System Analysis: The Key to Understanding Health Care Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
      April 22, 2004 - Work System Analysis: The Key to Understanding Health Care Systems 337 Work System Analysis: The Key to Understanding Health Care Systems Ben-Tzion Karsh, Samuel J. Alper Abstract Many articles in the medical literature state that medical errors are the result of systems problems, require systems analyses, a…

3606. Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Wideman.pdf
      April 20, 2004 - Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation 437 Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation Mary V. Wideman, Michael E. Whittler, Timothy M. Anderson Abstract An electronic barcode medication administration sy…

3607. The Patient Safety Education Project: An international Collaboration (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Emanuel_19.pdf
      February 20, 2008 - The Patient Safety Education Project: An international Collaboration The Patient Safety Education Project: An International Collaboration Linda Emanuel, MD, PhD; Merrilyn Walton, PhD; Martin Hatlie, JD; Denys Lau, PhD; Tim Shaw, PhD; Joel Shalowitz, MD, MBA; John Combes, MD Abstract The Patient Safety Edu…

3608. Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
      April 07, 2008 - Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures Stanley Davis, MD; William Riley, PhD; Ayse P. Gurses, PhD; Kr…

3609. Making Healthcare Safer Practices: 14. Delirium (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/delirium-1.pdf
      March 01, 2020 - Making Healthcare Safer Practices: 14. Delirium Delirium 14-1 14. Delirium Authors: Lynn Hoffman M.A., M.P.H., Aline Holmes D.N.P., R.N., Jennifer Riggs, Ph.D., R.N., and Stephanie Schneiderman, M.P.P. Introduction Patient safety research and quality improvement efforts have been underway in the delirium harm …

3610. Slide 1
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-focus-procedure-related-cath-use-070814.pptx
      January 01, 2015 - Yes No No, but we are considering it What is a post-removal protocol?

3611. Implementing Safety Cultures in Medicine: What We Learned by Watching Physicians (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Hoff.pdf
      January 01, 2003 - realities of health care work environments.1, 2, 11, 12 These realities need to be taken into account when considering

3612. Standardized infection ratios for central line-associated bloodstream infections and surgical site infections, 2009–2012
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt3.pptx
      September 19, 2015 - Standardized infection ratios for central line-associated bloodstream infections and surgical site infections, 2009–2012 Part 3: Trends in Access and Priorities of the National Quality Strategy National Healthcare Quality and Disparities Report Chartbook on Health Care for Hispanics 1 2014 QDR Chartbooks 2014 QDR …

3613. Chapter-7 - Harm Due to Anticoagulants (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/anticoagulants-1.pdf
      March 01, 2020 - Chapter-7 - Harm Due to Anticoagulants Harms Due to Anticoagulants 7-1 7. Harms Due to Anticoagulants Authors: Sarah J. Shoemaker-Hunt, Ph.D., Pharm.D., and Brandy Wyant, M.P.H. Introduction Anticoagulants are a critical therapy in the prevention and treatment of various types of thromboembolic disorders. Key in…

3614. 2016 AHRQ Nursing Home Survey on Patient Safety Culture Part I (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/nursing-home/2016/nhsurv16-pt1.pdf
      January 01, 2016 - 2016 AHRQ Nursing Home Survey on Patient Safety Culture Part I PATIENT SAFETY NURSING HOME SURVEY ON PATIENT SAFETY CULTURE: 2016 User Comparative Database Report The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Health…

3615. SOPS Workplace Safety Supplemental Items for Nursing Homes: 2025 Updated Results Part I (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2025_nursing_home_wps_ptI.pdf
      January 01, 2025 - SOPS Workplace Safety Supplemental Items for Nursing Homes: 2025 Updated Results Part I Surveys on Patient Safety Culture® (SOPS®) Workplace Safety Supplemental Items for Nursing Homes: 2025 Updated Results Part I Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Se…

3616. Final Progress Report: Encoding and Processing Patient Allergy Information in EHRs (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/zhou-report.pdf
      January 01, 2024 - Final Progress Report: Encoding and Processing Patient Allergy Information in EHRs AHRQ Grant Final Progress Report Title of Project: Encoding and Processing Patient Allergy Information in EHRs Principal Investigator: Li Zhou, MD, PhD Associate Professor Brigham and Women’s Hospital, Harvard Medical School Team…

3617. Final Progress Report: Improving patient safety through leadership and team performance in simulations (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/fernandez-report.pdf
      January 01, 2024 - Final Progress Report: Improving patient safety through leadership and team performance in simulations 1R18HS020295 Final Progress Report: Fernandez R, PI Title of Project: Improving patient safety through leadership and team performance in simulations Principal Investigator and Team Members: Fernandez, R (PI); Ko…

3618. Final Progress Report: Older adult safety while receiving home health services after hospital discharge (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/arbaje-report.pdf
      January 01, 2024 - Final Progress Report: Older adult safety while receiving home health services after hospital discharge Older adult safety while receiving home health services after hospital discharge Principal Investigator: Alicia I. Arbaje, MD, MPH, PhD Other team members: Bruce Leff, MD (Primary mentor) Ayse P. Gurses, PhD, MS…

3619. Developing a Community-Wide Electronic Shared Medication List (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Stock_113.pdf
      June 15, 2005 - Developing a Community-Wide Electronic Shared Medication List Developing a Community-Wide Electronic Shared Medication List Ron Stock, MD; Eldon R. Mahoney, PhD; Dawn Gauthier, MIS; Linda Center; Mary Minniti, CPHQ; James Scott, MD; Marc Pierson, MD; Lori Nichols Abstract This study demonstrates the feasib…

3620. New Models of Primary Care Workforce and Financing - Case Example #2: The Health Center (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_2.pdf
      October 01, 2016 - New Models of Primary Care Workforce and Financing - Case Example #2: The Health Center New Models of Primary Care Workforce and Financing Case Example The Health Center 2 New Models of Primary Care Workforce and Financing Case Example #2: The Health Center Prepared for: Age…