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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-Faltz_56.pdf
March 27, 2008 - The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures
1
The New York Model: Root Cause Analysis
Driving Patient Safety Initiative to Ensure
Correct Surgical and Invasive Procedures
Lawrence L. Faltz, MD, FACP; John N. Morley, MD, FACP…
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/patient-id-errors-1.pdf
March 01, 2020 - room
Three procedures (.6%) were
not marked prior to theater;
497 procedures were all
marked correctly … Although only 60%
of patients correctly mark
their surgery sites, it is still
determined to be the
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/McPhillips.pdf
January 01, 2004 - contribute to medication errors include
the following: (1) an accurate weight must be obtained and correctly … caregiver often will occur without the medication present; (7)
the prescription must be legible and correctly … Therefore, it is difficult for pharmacies to
correctly determine if a weight-based dosing error has
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/indwelling-urinary-catheter-use/catheter-insertion/unlicensed-staff/scenarios-instr.html
March 01, 2017 - Urinary Catheter Types and How To Care for Them Activity
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Staff Role Play—How good are your catheter care skills?
Roleplaying can be a helpful training and educational tool. Roleplaying allows staff to actively practice the skills they are learni…
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
October 01, 2018 - Improvement in Taking Medication Correctly
• Importance: Taking medications correctly is important … Home health care patients who got better at taking their medications
correctly by mouth, 2010-2016 … Home health care patients who got better at taking their medications
correctly by mouth, 2010-2016 … patients got better at taking their
medications correctly by mouth, by State
Source: Centers for … Relative Change in Taking Medication Correctly, by State
Patient Safety in the Ambulatory Setting
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www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/redtool5.html
March 01, 2025 - Do this until the patient can correctly describe your directions in his or her own words. … If medication reconciliation was done correctly at discharge, these lists should match.
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www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool5.html
March 01, 2025 - Do this until the patient can correctly describe your directions in his or her own words. … If medication reconciliation was done correctly at discharge, these lists should match.
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www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdf
January 01, 2024 - This
allows the pharmacist to verify that the labels print correctly.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-transcript-508-compliant.pdf
June 01, 2017 - Just Culture Webcast November 2016
Using Just Culture to Improve Hospital Survey on Patient Safety Culture Results
November 9, 2016 – Webcast Transcript
Speakers:
Celeste Mayer, PhD
Patient Safety Officer, University of North Carolina Health Care System, Chapel Hill, NC
(Presenter)
Theresa Famolaro, MPS, MS…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/medical-office/resources/infotransMOSOPS.pdf
January 01, 2010 - We have good procedures for checking that work in this office was done correctly. … about this item: After a work task is done, we have quality-control steps for making sure it
was done correctly
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_facguide.docx
May 01, 2017 - If so, were they performed correctly or could they be improved? … They can explain how and why certain outcomes may have happened “Was the decision made right (correctly
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www.ahrq.gov/sops/international/medical-office/translators.html
January 01, 2010 - We have good procedures for checking that work in this office was done correctly. ( More about this item … : After a work task is done, we have quality-control steps for making sure it was done correctly .)
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/MO_Items-Composite_Measures.pdf
June 02, 2025 - We have good procedures for checking that work in this office was done correctly.
C12.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar8_pu_sustainingpractices.pdf
April 01, 2011 - – For instance, reward unit staff the first time they
complete a skin documentation form correctly
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/3-bestpractices-web-sopssurveys-famolaro.pdf
September 01, 2020 - Best Practices for Web-based SOPS Surveys - Famolaro Slides
Web-based SOPS Surveys
Theresa Famolaro, MPS, MS, MBA
Senior Study Director and SOPS Database Manager
User Network for the AHRQ Surveys on Patient Safety Culture (SOPS)
Westat
12
Use of Web in SOPS Surveys
25%
45%
76%
83%
2007 2010 2014 2018
% o…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/allergies-guide.docx
September 01, 2022 - When done correctly, penicillin skin testing is highly predictive of serious anaphylactic reactions. … allergy, modify the medical record as needed, and ensure that the patient understands the importance of correctly
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www.ahrq.gov/teamstepps-program/curriculum/implement/activity/coach.html
June 01, 2023 - When a behavior is performed correctly, it is critical for coaches to identify what was good about the … When behavior is not performed correctly or shows room for improvement, coaches must point out not only
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-k-study-elements.docx
June 02, 2025 - Quality Improvement Study Framework
Element
Definition
Things To Keep in Mind
The Purpose
Define the problem and why it is important.
· Avoid suggesting causes in the purpose statement. Cause determination will come later after the data have been analyzed.
· Speculating about the cause of a problem before a th…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/study.html
May 01, 2017 - Appendix K. Quality Improvement Study Framework - Implementation Guide
Study Elements
Element
Definition
Things To Keep in Mind
The Purpose
Define the problem and why it is important.
Avoid suggesting causes in the purpose statement. Cause determination will come later afte…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_3_communication.pptx
July 01, 2023 - By the end of this cycle, the sender and receiver both know information was communicated correctly. … it’s especially important to acknowledge and confirm you have heard the blood pressure measurement correctly … transport
During recognition of a hypertensive patient:
Use check-backs to ensure that warning signs are correctly … having a unit-recognized procedure for organizing your communications and ensuring information has been correctly