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  1. www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/advance-organizational-safety-strategies-slides.pdf
    June 18, 2024 - NAA National Webinar May 2024 - Understanding and Operationalizing the National Action Alliance Aim #1: Advance Organizational Safety Strategies Using National Action Plan Foundations Understanding and Operationalizing the National Action Alliance Aim #1: Advance Organizational Safety Strategies Using National Act…
  2. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Shaha.pdf
    May 01, 2004 - Establishing a Culture of Patient Safety Through a Low-tech Approach to Reducing Medication Errors 333 Establishing a Culture of Patient Safety Through a Low-tech Approach to Reducing Medication Errors Steven H. Shaha, Linda Brodsky, Michael S. Leonard, Michael A. Cimino, Sandra A. McDougal, Joann M. Pilliod…
  3. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
    December 01, 2017 - This team includes the team’s facilitator, champion, unit manager, provider champion, and the senior executive … The senior executive can offer organizational vision and inform about interventions that the organization
  4. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/2024-virtual-research-meeting-summary-prems-proms.pdf
    January 01, 2024 - Patient-Centered Outcome Measures in Value-Based Healthcare Elizabeth Teisberg Elizabeth Teisberg, Ph.D., Executive … Shaller, M.P.A., Principal, Shaller Consulting Group Moderator for Part III: Susan Edgman-Levitan, P.A., Executive
  5. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-3.html
    June 01, 2021 - Leadership To Improve Diagnosis: A Call to Action How Can Leaders Drive Improvements in Diagnostic Safety? Previous Page Next Page Table of Contents Leadership To Improve Diagnosis: A Call to Action Diagnostic Safety as a Challenge for Healthcare Leadership Why Are Leaders Essential to Diagnosti…
  6. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_ssi_investigation_facnotes.docx
    December 01, 2017 - Facilitator Guide: Sustaining and Spreading Surgical Safety Improvements Performing an SSI Investigation – Facilitator Notes Slide Title and Commentary Slide Number and Slide Performing an SSI Investigation SAY: In this module, you’ll learn about performing a surgical site infection or SSI investigation. Slide …
  7. www.ahrq.gov/hai/tools/surgery/modules/on-boarding/ssi-investigation-fac-notes.html
    December 01, 2017 - Performing an SSI Investigation: Facilitator Notes AHRQ Safety Program for Surgery Slide 1: Performing an SSI Investigation Say: In this module, you’ll learn about performing a surgical site infection or SSI investigation. Slide 2: Learning Objectives Say: Here are the objectives. We want to d…
  8. www.ahrq.gov/hai/cusp/toolkit/learn-defects.html
    December 01, 2012 - Learn from Defects Tool CUSP Toolkit Health care organizations can increase the extent to which they learn from defects. Problem statement: Health care organizations can increase the extent to which they learn from defects. We define this learning as reducing the probability that a future patient will be h…
  9. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load3.html
    May 01, 2024 - Cognitive Load Theory and Its Impact on Diagnostic Accuracy Interplay Between Cognitive Load and Diagnostic Accuracy Previous Page Next Page Table of Contents Cognitive Load Theory and Its Impact on Diagnostic Accuracy Introduction to Diagnostic Errors Fundamental Concepts for Understanding Cogn…
  10. Learndefects (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/learndefects.doc
    June 02, 2025 - Learn From Defects Tool Problem statement: Health care organizations can increase the extent to which they learn from defects. We define this learning as reducing the probability that a future patient will be harmed. Most often clinicians recover from mistakes by reducing risks to the patient who suffered a defect. Wh…
  11. www.ahrq.gov/news/newsletters/e-newsletter/932.html
    October 01, 2024 - Highlighting the Urgent Need for Research on Improving Delivery of Preventive Services to People with Disabilities Issue Number 932 AHRQ News Now is a weekly newsletter that highlights agency research and program activities. October 8, 2024 AHRQ Stats: In-Hospital Sepsis Mortality Rate Disparities While…
  12. www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-19-kickoff-meetings.pdf
    September 01, 2015 - Module 19: Conducting a Kickoff Meeting Primary Care Practice Facilitation Curriculum Module 19: Conducting a Kickoff Meeting Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov …
  13. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/133-translating-research-into-practice-fg.docx
    April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI Translating Research into Practice (TRiP) Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries Slide Title and Commentary Slide Number and Slide Translating Research into Practice (TRiP) SAY: This presentation is on Trans…
  14. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Leape.pdf
    June 02, 2025 - Prologue -- Where the Rubber Meets the Road 1 Prologue Where the Rubber Meets the Road Lucian L. Leape Traditionally, a primary focus of patient safety research has been to analyze data to identify problems and demonstrate that a new practice will lead to improved quality or safety. Much less research att…
  15. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_facguide.pdf
    May 01, 2017 - AHRQ Safety Program for Perinatal Care: Establishing a Program of In Situ Simulations AHRQ Safety Program for Perinatal Care Establishing a Program of In Situ Simulations AHRQ Publication No. 17-0003-22-EF May 2017 SAY: Establishing a Program of In Situ Simulations is a pillar of the AHRQ Safety Program for…
  16. www.ahrq.gov/sites/default/files/2024-07/peck-report.pdf
    January 01, 2024 - Mitchell Dvorak, Executive Director, Consumers Advancing Patient Safety, assisted in drafting appendices … administrators (including acute, ambulatory and long-term care facilities)  Healthcare facilities executive … Irving, TX 75039 (W) 972-830-0224 (F) 972-830-0332 lmisuk@vha.com Virginia Morrison, JD Executive … 77030 (W) 713-745-1357 (F) 713-745-4437 (H) 281-293-0175 jasonetchegaray@yahoo.com Roger Fritz Executive
  17. www.ahrq.gov/workingforquality/events/webinar-federal-agency-alignment-to-the-six-priorities.html
    November 01, 2016 - Nancy Wilson, Executive Lead for the National Quality Strategy, will give a brief overview of the Strategy
  18. www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/key_drivers_descriptions.pdf
    February 01, 2019 - EvidenceNow Key Drivers and Change Strategies EvidenceNow Key Drivers and Change Strategies Tools & Resources Change Strategy: Develop a process to search for new evidence and other changes related to Key Driver 1 Change Strategy: Develop an inter-professional QI team and other changes related to Key Driver…
  19. www.ahrq.gov/evidencenow/tools/keydrivers/description.html
    October 01, 2020 - EvidenceNow Key Drivers and Change Strategies Below are descriptions of each key driver and change strategy in the EvidenceNOW Key Driver Diagram. Key Driver 1: Seek, select, and customize the best evidence for use by the practice The practice of medicine evolves in response to new knowledge about what care…
  20. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Scanlon_62.pdf
    March 25, 2008 - Risk-Based Patient Safety Metrics Risk-Based Patient Safety Metrics Matthew C. Scanlon, MD; Ben-Tzion Karsh, PhD; Kelly A. Saran, MS, RN Abstract Patient safety programs require meaningful metrics. Dominant frameworks are based on two safety metrics: one that seeks to identify, measure, and eliminate error an…

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