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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/19-perioperative-teams.docx
June 01, 2023 - Lead by example
Do the work to show commitment and to motivate others. … For example, her team decided to increase the percentage of patients prescribed multimodal analgesic … For example, Deb Hobson, a safety and quality improvement nurse at The Johns Hopkins Hospital, found … Domain 4 Example: Have a Structured Approach to Learning[footnoteRef:3] [3: Behavior linked to Domain … As an example of an innovative way to support a structured approach to learning, Dr.
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www.ahrq.gov/patient-safety/reports/advances/planning.html
July 01, 2022 - For example—A decision support device, an educational curriculum, data collection tool, etc. … For example—Is it an innovative way to tackle an existing problem? Does it identify a new problem? … For example—does it increase efficiency? Improve quality of care? Provide legal protection? … For example—Have nurses evaluate the use of an infusion pump. … End users
Individual/Organizations/Networks
Importance of end users
For example:
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psnet.ahrq.gov/issue/promoting-patient-safety-through-prospective-risk-identification-example-peri-operative-care
September 23, 2020 - Study
Promoting patient safety through prospective risk identification: example from … Promoting patient safety through prospective risk identification: example from peri-operative care. … Promoting patient safety through prospective risk identification: example from peri-operative care.
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www.ahrq.gov/hai/tools/mrsa-prevention/surgery/learning-from-defects.html
April 01, 2025 - Describe a process to help teams learn from defects Explore the Learning From Defects tool Work through an example … Review the definition of a defect Review the “Swiss cheese model” of system failure Apply a patient example … Tool: Learning From Defects Completed Form (DOCX, 411 KB) An example of a completed Learning From Defects
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digital.ahrq.gov/sites/default/files/docs/page/4_GuidelinesforDescribingBusinessPractices_1.pdf
June 16, 2021 - We also recommend that all teams review the example spreadsheet
in Tool 5, Example Business Practices … For example, if a team representing South Dakota collected a number of different business
practices … Example 2:
“Often the state is not aware of the case and many people do not know the
programs that … Example:
Reference number: State Health and Safety Code 611.004 (7). … Example:
Reference number: State Code 444.912 (3).
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digital.ahrq.gov/sites/default/files/docs/page/4_GuidelinesforDescribingBusinessPractices_0.pdf
June 16, 2021 - We also recommend that all teams review the example spreadsheet
in Tool 5, Example Business Practices … For example, if a team representing South Dakota collected a number of different business
practices … Example 2:
“Often the state is not aware of the case and many people do not know the
programs that … Example:
Reference number: State Health and Safety Code 611.004 (7). … Example:
Reference number: State Code 444.912 (3).
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psnet.ahrq.gov/node/866217/psn-pdf
July 10, 2024 - Amy Helwig: One example is having strong credentialing programs in place. … Another example of the impact of the health plan is through policies on what we include in our benefit … For example, if a state health department indicates lead screening as important for the state, they … Amy Helwig: One example is prescription drugs. … Another example is access to care.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pressureinjury-msmt_slides.pptx
June 02, 2025 - helps you determine incidence and prevalence rates.
21
Incidence Calculation
Monthly Unit Numbers Example … Annotation: Show your interventions.
27
27
Annotated Run Chart Example
Intervention: Unit education … 42186 42217 42248 42278 42309 42339 42370 42401
Number of Pressure Injuries
Annotated Run Chart Example … Tool 5D provides a sample protocol for assessing performance.
38
Risk Assessment Measurement Example … Ensure that the care plan addresses all areas of risk.
40
40
Care Plan Measurement Example
Tool
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digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/GroundRulesForConductingaRiskAssessment.pdf
January 01, 2010 - (For example, “followup for high risk diabetics.”)
• Limit the scope. … (For example, “diabetics with poor compliance. … (For example, “assess what the system provides that facilitates
the process. … (For example, “consequences for high
risk diabetes with poor control can be grave. … (For
example, “ensure proposed workflow of high risk diabetic patient follow-up is
documented.
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www.ahrq.gov/sites/default/files/wysiwyg/lhs/lhs_case_studies_denver_health.pdf
April 01, 2019 - For example, Denver Health’s EHR has been designed to allow its primary care clinics to
incorporate … For example, asking what can be learned when something goes wrong led
to the development of a systemwide … Another example of how Denver Health has embraced a culture of continuous improvement is
the use of … For example, Denver Health leaders initially assumed there was a correlation between repeat
emergency … For example, it recently
expanded its management incentive plan to include more key managers.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses2.html
August 01, 2022 - all have a direct impact on cognition and will shape clinical reasoning, for better or worse. 17 For example … For example, paper and electronic tools developed to facilitate handoffs between clinicians are a type … For example, a nurse assesses the patient upon initial presentation to the ED, demonstrating the physical … For example, as part of a newly established workflow, the nurse and physician go into a patient’s room
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psnet.ahrq.gov/node/39349/psn-pdf
March 23, 2011 - Promoting patient safety through prospective risk
identification: example from peri-operative care. … Promoting patient safety through prospective risk identification: example
from peri-operative care. … https://psnet.ahrq.gov/issue/promoting-patient-safety-through-prospective-risk-identification-example-peri … https://psnet.ahrq.gov/issue/promoting-patient-safety-through-prospective-risk-identification-example-peri-operative-care … https://psnet.ahrq.gov/issue/promoting-patient-safety-through-prospective-risk-identification-example-peri-operative-care
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/Best_Practices_Hosp_Leaders_508.pdf
March 13, 2013 - For example, as part of a
process to integrate various entities under a common organizational umbrella … For example,
the former chief executive officer of the University of Colorado Hospital in Aurora,
CO … For example, Cincinnati Children’s Hospital created a core corporate function,
housing patient- and … For example, the University of
Washington Medical Center’s Office of Medical Affairs in Seattle, WA, … As another
example, hospitals may wish to invest in the physical environment.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/safetransitions/safetrans_apptaide.pdf
December 01, 2017 - (For example, “I get short of breath walking up my stairs,” or
“Should I take my insulin if my blood … (For example, when to take medicines, or when to
follow up)
2. What can I do to help the patient? … (For example, what is my role in helping the patient at home? … (For example, training, home nurse visits, meal delivery)
5. Can I physically perform the tasks? … (For example, join a support group, hire someone to help
provide care, make sure I am not ignoring my
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www.ahrq.gov/cahps/consumer-reporting/guidelines/distribution/index.html
March 01, 2016 - For example, many people focus more on health care-related information received at home than information … For example, will they want to interact with it by taking notes or circling specific information? … For example, while patients may have a choice of hospitals, this choice is typically constrained by both … Consumers selecting a health plan, for example, typically rely on lists of participating providers, schedules … (For example, you could include survey results for doctors or health plans as part of a health plan enrollment
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
April 01, 2025 - the definition of a defect, review the “Swiss cheese model” of system failure, and apply a patient example … For example, an anesthesiologist administers the wrong antibiotic or gives the wrong dose of an antibiotic … For example, a patient receives the right antibiotic and the right dose but receives the antibiotic too … For example, issues related to teamwork, communication, or supervision could have contributed. … For example, the protocol for preoperative decolonization was not easily accessible in the clinic.
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu6.html
October 01, 2014 - For example, if the Implementation Team has been chartered as an ad hoc, time-limited quality improvement … On the other hand, if there is no other team—for example, the Skin Committee has too many responsibilities … Reward changed behavior at the unit level: For example, you might start by giving certificates to the … Reward changed behavior at the individual level: For example, you might ask Unit Champions to nominate … For example, one hospital noticed an increase in tubing-related pressure ulcers.
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www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu6.html
October 01, 2014 - For example, if the Implementation Team has been chartered as an ad hoc, time-limited quality improvement … On the other hand, if there is no other team—for example, the Skin Committee has too many responsibilities … Reward changed behavior at the unit level: For example, you might start by giving certificates to the … Reward changed behavior at the individual level: For example, you might ask Unit Champions to nominate … For example, one hospital noticed an increase in tubing-related pressure ulcers.
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/projects/state/how-to-guide/how-to-guide.pdf
August 01, 2024 - For example, Healthy Hearts for Michigan developed a monthly e-newsletter
for partners (see an example … For example, participation might require staff to take time away from billable
activities. … An example is Tennessee Heart Health Network’s letter of intent. … For example, see a PDF version
of Tennessee Heart Health Network’s e newsletter. … For example:
• Practice engagement.
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www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/medical-office/2014/mosurv14notes.html
June 01, 2014 - For example, for a three-item composite, if the item-level percent positive responses were 50 percent … Table N1 shows an example of computing a composite score for Staff Training :
This composite has … Calculate the percentage of positive responses at the item level (refer to example in Table N1 ). … In this example, an average of about 50 percent of the respondents responded positively to the survey … For example, to calculate the 10 th percentile, one would multiply 935 (the total number of medical