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www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/harrison-summit2016-breakout.pdf
September 28, 2016 - 28, 2016
Overview
• NAM Report: Framework for thinking about
organizational factors
• Research Examples … collaboration and teamwork,
communication, feedback, learning, patient-
centered care
Research Examples … system to
improve communication and teamwork skills among
health care professionals
Research Examples … Diagnostic Quality
Overview
Work System
Organizational Factors Likely to Affect Diagnosis
Research Examples … Research Examples (cont’d)
Appendix: AHRQ Resources
Acrobat Accessibility Report
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www.ahrq.gov/hai/cusp/clabsi-hpwpreport/clabsi-hpwpap.html
August 01, 2015 - Examples include profit-related pay, gain-sharing, and goal-anchored bonuses. … Examples include referral incentives to current employees, employee branding, and alumni programs. … Examples include validated selection tools such as personality assessments, work samples, biodata, and … Examples include policies and practices supporting open communication across disciplines. … Examples include use of core competency models and/or incorporation of goals to guide training, assessment
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_obhemorrhage.docx
May 01, 2017 - Safety Elements
Standardize When Possible (CUSP Science of Safety)
Key Perinatal Safety Elements
Examples … Standardize When Possible (CUSP Science of Safety) (continued)
Key Perinatal Safety Elements
Examples … Standardize When Possible (CUSP Science of Safety) (continued)
Key Perinatal Safety Elements
Examples … Options and examples for a standardized approach include the following:
· Evidence of benefit and harms … · Examples of checklists, flow sheets, protocols, and algorithms for clinical response to obstetric
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digital.ahrq.gov/sites/default/files/docs/page/5_Example%20Business%20Practices.xls
June 16, 2021 - Example Business Practices
6 Examples
Business Practice Name Business Practice Long Description Scenario
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hcup-us.ahrq.gov/datainnovations/clinicaldata/FL20LOINCIntroductionHammond.pdf
February 25, 2008 - separate axes
25 Feburary 2008 Hammond 7
COMPONENT
• What is measured, evaluated or observed
• Examples … C antigen
25 Feburary 2008 Hammond 8
PROPERTY MEASURED
• Characteristics of what is measured
• Examples … 2008 Hammond 10
SAMPLE/SYSTEM
• Context or specimen type within which the
observation was made
• Examples … :24H:UR:QN
• GLUCOSE^2H POST 100 G GLUCOSE
PO:MCNC:PT:SER/PLAS:QN
25 Feburary 2008 Hammond 20
EXAMPLES … (1)
EXAMPLES (2)
EXAMPLES (3)
Clinical LOINC
Examples
LOINC Today
Regenstrief LOINC Mapping Assistant
-
psnet.ahrq.gov/node/845653/psn-pdf
March 08, 2023 - Examples of Medical Device Misconnections.
March 8, 2023
Food and Drug Administration. … https://psnet.ahrq.gov/issue/examples-medical-device-misconnections
Mismatches of medical device connectors … https://psnet.ahrq.gov/issue/examples-medical-device-misconnections
https://psnet.ahrq.gov/issue/managing-risk-during-transition-new-iso-tubing-connector-standards
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/aRJ-3-AWuVvmC_kmoGCVHp
postpartum
hemorrhage; blood
transfusion;
postpartum
depression
Infant health
outcomes:
Examples … no screening
comparison
KQ1: Maternal
health outcomes:
Examples include
mortality; health-
related … Population
Intervention/
Comparison Outcomes/ Timing Setting
Maternal
intermediate
outcomes:
Examples … and ferritin levels;
low birth weight,
small for gestational
age, and preterm
delivery
KQ2: Examples … be needed to
link intermediate
outcomes to health
outcomes
Maternal
intermediate
outcomes:
Examples
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www.ahrq.gov/action-alliance/engineering-safety-practice/index.html
April 01, 2025 - document provides an overview of some safety engineering principles, strategies, change concepts, and examples … Examples Continuous Monitoring with Sedative and Analgesia Administration . * Inpatient Respiratory Arrest … Examples Resuscitation Cart Medication Drawer Redesign. … Assessment and Remediation Tool [HART] for Simulation-Based Healthcare Facility Design Testing . * Examples … I-PASS handoff tool. * Examples Applying the Medications at Transitions and Clinical Handoffs
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/multiple/Calibrate-Dx-AppendixA.pdf
June 02, 2025 - Case Review Plan
FOCUS OF CALIBRATION
(Examples: diagnosis-specific situations, undifferentiated presentations … interpretation
Followup and tracking
DATA SOURCE(S) OR SELECTION CRITERIA FOR RECORDS REVIEWED:
(Examples … Fishbone Diagram Other No specific tool used
CALIBRATION QUESTION(S) CONSIDERED (SEE TABLE 3 FOR EXAMPLES
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www.ahrq.gov/research/findings/final-reports/ptmgmt/evaluation-table3a.html
July 01, 2018 - Examples of Evaluation Measures for Self-management Support Programs for Common Chronic Conditions … Examples are taken from the literature.
Return to Document
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/tool_safe-oxytocin.docx
May 01, 2017 - Administration—Oxytocin
Purpose of the tool: This tool describes the key perinatal safety elements with examples … Several professional organizations, guidelines, and evidence reviews offer examples of maternal and fetal … Standardize When Possible (CUSP Science of Safety) (continued)
Key Perinatal Safety Elements
Examples … Create Independent Checks (CUSP Science of Safety)
Key Perinatal Safety Elements
Examples
Assess … Learn From Defects (CUSP Module)
Key Perinatal Safety Elements
Examples
Debrief and analyze near
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/tool_rapidresponse-systems.docx
May 01, 2017 - Safety Elements
Standardize When Possible (CUSP Science of Safety)
Key Perinatal Safety Elements
Examples … Learn From Defects (CUSP Module)
Key Perinatal Safety Elements
Examples
Debrief and analyze near … Learn From Defects (CUSP Module) (continued)
Key Perinatal Safety Elements
Examples
Have a process … Teamwork Training (TeamSTEPPS®)
Key Perinatal Safety Elements
Examples
Have situational awareness … Patient and Family Engagement (CUSP Module)
Key Perinatal Safety Elements
Examples
Use mechanism
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www.ahrq.gov/research/publications/ahrq-info-quality-gdlns-update.html
June 01, 2018 - Examples include consumer publications on: various health conditions/diseases, on how to select a health … Examples of publications for professionals include evidence reports on a wide array of clinical topics … Other examples are toolkits that give easy-to-understand guidance on how to implement quality improvements
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapc.html
December 01, 2017 - Case Study and Program Examples
Previous Page Next Page
Table of Contents
The Falls … Case Study and Program Examples
Appendix D.
-
www.ahrq.gov/research/findings/final-reports/ptflow/appendix-a.html
April 01, 2020 - D: Additional Readings
The Urgent Matters Toolkit
This toolkit includes over 50 examples … Healthcare Research and Quality (AHRQ) Innovations Exchange
The Innovations Exchange includes over 75 examples … ACEP)
ACEP's Emergency Medicine Crowding and Boarding resources provide information, resources, and examples
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-pdsa-form.docx
May 01, 2017 - Module 2: Example
AHRQ Safety Program for Ambulatory Surgery
Management Practices for Sustainability
Module 5: Visual Management
Sample “Plan-Do-Study-Act”[footnoteRef:1] Form [1: “Plan-Do-Study-Act” refers to a method for testing changes in clinical practice. In the “plan” step, lay out the specifications of your…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/huddles/example-pdsa-form.docx
May 01, 2017 - Module 2: Example
AHRQ Safety Program for Ambulatory Surgery
Management Practices for Sustainability
Module 2: Daily Huddles
Sample “Plan-Do-Study-Act”[footnoteRef:1] Form [1: “Plan-Do-Study-Act” refers to a method for testing changes in clinical practice. In the “plan” step, you lay out the specifications of you…
-
www.ahrq.gov/hai/cauti-tools/phys-championsgd/index.html
October 01, 2015 - Device-Associated Infections
Preamble and Summary
Epidemiology of Invasive Devices and Complications
Examples … and Source Information
Preamble
Summary
Epidemiology of Invasive Devices and Complications
Examples
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Shah_99.pdf
March 23, 2008 - Table 2 contains all 16 responses.
5
6
Examples of adverse events due to negligence. … responses with inadequate information or context for reliable assessment (12
examples). … However, respondents had difficulty providing examples of adverse events due to negligence. … Most respondents provided examples of negligence but not negligence-based adverse events. … responses with inadequate information or context for reliable assessment (12 examples).
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www.ahrq.gov/cahps/consumer-reporting/index.html
October 01, 2024 - Examples of Comparative Reports Illustrative examples of web-based comparative reports for consumers … Organizations that are developing comparative reports can use these examples to better understand the