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2101. Making Health Care Safer II, Executive Summary (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetysum.pdf
      March 01, 2013 - Making Health Care Safer II, Executive Summary Evidence-Based Practice Evidence-based Practice Program The Agency for Healthcare Research and Quality (AHRQ), through its Evidence- based Practice Centers (EPCs), sponsors the development of evidence reports and technology assessments to assist public- and priv…

2102. Six Building Blocks How-To-Implement Toolkit: Fast Track Approach Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/ambulatory/6bb-toolkit-fasttrack.pdf
      January 12, 2021 - Six Building Blocks How-To-Implement Toolkit: Fast Track Approach Guide A Team-Based Approach to Improving Opioid Management in Primary Care Table of Contents Introduction ......................................................................................................................................1 W…

2103. A Study of Adverse Occurrences and Major Functional Impairment Following Surgery (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Rojas.pdf
      March 15, 2004 - A Study of Adverse Occurrences and Major Functional Impairment Following Surgery 275 A Study of Adverse Occurrences and Major Functional Impairment Following Surgery Mary Rojas, Alan Silver, Christine Llewellyn, Lenora Rances Abstract Objective: The authors sought to ascertain whether adverse occurrences (AOs…

2104. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
      January 01, 2003 - Do Transient Working Conditions Trigger Medical Errors? 53 Do Transient Working Conditions Trigger Medical Errors? Deborah Grayson, Stuart Boxerman, Patricia Potter, Laurie Wolf, Clay Dunagan, Gary Sorock, Bradley Evanoff Abstract Objective: Organizational factors affecting working conditions for health …

2105. 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…

2106. Diagnostic Failure: A Cognitive and Affective Approach (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
      January 01, 2004 - Diagnostic Failure: A Cognitive and Affective Approach 241 Diagnostic Failure: A Cognitive and Affective Approach Pat Croskerry Abstract Diagnosis is the foundation of medicine. Effective treatment cannot begin until an accurate diagnosis has been made. Diagnostic reasoning is a critical aspect of clinic…

2107. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
      January 01, 2004 - “Near-miss” Reporting System Development and Implications for Human Subjects Protection 181 “Near-miss” Reporting System Development and Implications for Human Subjects Protection Harvey J. Murff, Daniel W. Byrne, Paul A. Harris, Daniel J. France, Christa Hedstrom, Robert S. Dittus Abstract Background: R…

2108. Role of the External Coach in Advancing Research Translation in Hospital-Based Performance Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Donaldson_87.pdf
      April 23, 2008 - Role of the External Coach in Advancing Research Translation in Hospital-Based Performance Improvement Role of the External Coach in Advancing Research Translation in Hospital-Based Performance Improvement Nancy Donaldson, RN, DNSc, FAAN; Dana Rutledge, RN, PhD; Kristin Geiser, PhD Abstract The Califo…

2109. Pillars of a Smart, Safe Operating Room (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Seagull_98.pdf
      April 07, 2008 - Pillars of a Smart, Safe Operating Room Pillars of a Smart, Safe Operating Room F. Jacob Seagull, MD; Gerald R. Moses, PhD; Adrian E. Park, MD Abstract Major gains in patient safety can be achieved through development of innovative approaches to the care of surgical patients. Investigators and clinicians have…

2110. Screening for Asymptomatic Coronary Artery Disease: Systematic Evidence Review (pdf file)
      www.ahrq.gov/downloads/pub/prevent/pdfser/chdser.pdf
      December 08, 2003 - Screening for Asymptomatic Coronary Artery Disease: Systematic Evidence Review This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or a basis for reimbursement and coverage…

2111. Making Healthcare Safer Practices: 16. Venous Thromboembolism (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/venous-thromboembolism-1.pdf
      March 01, 2020 - Making Healthcare Safer Practices: 16. Venous Thromboembolism Venous Thromboembolism 16-1 16. Venous Thromboembolism Eleanor Fitall, M.P.H., and Kendall K. Hall, M.D., M.S. Introduction Background Venous thromboembolism (VTE) is a disorder that includes deep vein thrombosis (DVT) and pulmonary embolism (PE). …

2112. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/erepguide.html
      April 01, 2016 - Slide 16: Reviewing Calculation Details for Weight Summary Report Do: Review the weight item definitions

2113. Final Progress Report: Improving Safety After Hospitalization in Older Persons on High-Risk Medications (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/gurwitz2-report.pdf
      January 01, 2024 - assessed and published on the reliability and validity of the approaches that were employed.8,29,45,46 Definitions

2114. Final Progress Report: California Intensive Care Outcomes (CALICO) Project Final Report (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/dudley-report.pdf
      January 01, 2025 - We are currently reconfiguring this variable to use alternative ventilator day definitions.

2115. Chapter-8 - Diabetes (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/diabetes-1.pdf
      March 01, 2020 - Teach-back is in a formative stage in that enhanced definitions and typologies of teach-back methods

2116. Eliminating CLABSI, A National Patient Safety Imperative: Final Report (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/clabsifinal.pdf
      October 01, 2012 - National content calls and State lead meetings featured CDC and HHS as faculty to explain data definitions

2117. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Training | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/reportguide.html
      November 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Training Facilitator Training Instructor Guide Slide 1: Introduction to Falls Reports AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training Introduction to Falls Reports Say: In this session we will in…

2118. Webinar Transcript - National Quality Strategy: 2013 Annual Progress Report Update | Agency for Healthcare Research and Quality
      www.ahrq.gov/workingforquality/events/webinar-2013-annual-progress-report-update.html
      November 01, 2016 - Webinar Transcript - National Quality Strategy: 2013 Annual Progress Report Update August 8, 2013 Download accessible version of slides (PDF, 920 KB) National Quality Strategy: 2013 Annual Progress Report Update [Slide 1] Ann Gordon: Welcome everyone. My name is Ann Gordon and I'll be facilitating…

2119. Using the AHRQ Medical Office Survey on Patient Safety Culture (SOPS) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/using-medical-office-transcript.pdf
      April 29, 2011 - Using the AHRQ Medical Office Survey on Patient Safety Culture (SOPS) Using the AHRQ Medical Office Survey on Patient Safety Culture Webinar Transcript April 29, 2011 A conference call conducted on April 29, 2011, provided users with an overview of the development and use of the Medical Office Survey on Patien…

2120. Webinar Transcript - National Quality Strategy Webinar: Using the Nine Levers to Achieve Results | Agency for Healthcare Research and Quality
      www.ahrq.gov/workingforquality/events/webinar-using-the-nine-levers-to-achieve-results.html
      November 01, 2016 - Webinar Transcript - National Quality Strategy Webinar: Using the Nine Levers to Achieve Results August 19, 2014 Download accessible version of slides (PDF, 2.4 MB) National Quality Strategy Webinar: Using the Nine Levers to Achieve Results [Slide 1] Ann Gordon:  Good afternoon everyone. We want to…