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2021. References | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-5.html
      June 01, 2020 - Triggers and Targeted Injury Detection Systems (TIDS) Expert Panel Meeting: Conference Summary Report

2022. Final Progress Report: Diagnostic Error in Dystonia (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/tanner-report.pdf
      January 01, 2025 - Utilization records were reviewed by study expert physicians (Drs.

2023. Final Progress Report: Improved Patient Safety with Information Technology (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/overhage-report.pdf
      January 01, 2024 - and guidelines implementation using clinical decision support systems • Held regular (bi-weekly) expert

2024. Module 1: Preventing Pressure Injuries in Hospitals—Understanding Why Change Is Needed | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/guide1.html
      October 01, 2017 - Module 1: Preventing Pressure Injuries in Hospitals—Understanding Why Change Is Needed Training Guide Module Aim The aim of Module 1 is to introduce the Preventing Pressure Ulcers in Hospitals Toolkit training. Module Goals The goals of this introductory module are to identify the overall objectives…

2025. Creating and Maintaining a Culture of Safety Series (Session 3): Measuring and Responding to Safety Culture Across Healthcare (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/measuring-safety-culture.pdf
      May 13, 2025 - Creating and Maintaining a Culture of Safety Series (Session 3): Measuring and Responding to Safety Culture Across Healthcare Creating and Maintaining a Culture of Safety Series (Session 3) Measuring and Responding to Safety Culture Across Healthcare NATIONAL WEBINAR SERIES April 15, 2025 Housekeeping Instructi…

2026. Final Progress Report: Infection Prevention in Emergency Care: A Systems Approach (pdf file)
      www.ahrq.gov/sites/default/files/2025-05/schuur-report.pdf
      January 01, 2025 - Final Progress Report: Infection Prevention in Emergency Care: A Systems Approach Title: Infection Prevention in Emergency Care: A Systems Approach Principal Investigator: Jeremiah D. Schuur, MD, MHS Team Members: Conference Co-Chair: Connie Price, MD Project Coordinator: Corine Sinnette, MA Organization: Brigh…

2027. Evaluation Highlight No. 7: How are CHIPRA quality demonstration States designing and implementing caregiver peer support programs? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight07.pdf
      September 08, 2015 - Evaluation Highlight No. 7: How are CHIPRA quality demonstration States designing and implementing caregiver peer support programs? The CHIPRA Quality Demonstration Grant Program In February 2010, the Centers for Medicare & Medicaid Services (CMS) awarded 10 grants, funding 18 States, to improve the quality of h…

2028. Sensemakingnotes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
      June 02, 2025 - SAY: The “Identify Defects Through Sensemaking” module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit will help you identify recurring defects in your system and apply CUSP and Sensemaking tools to help reduce the risk of future harm to your patients. Slide 1 SAY: Some of the tools that will help…

2029. Introduction to the SPPC-II Teamwork Toolkit for Obstetric Hemorrhage - PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_1-introduction.pptx
      July 01, 2023 - Introduction to the SPPC-II Teamwork Toolkit for Obstetric Hemorrhage - PowerPoint Presentation Introduction to the SPPC-II Teamwork Toolkit for Severe Hypertension Module 1 of 8 SPPC-II Toolkit AHRQ Pub. No. 23-0046 July 2023 Hospital AIM Team Leads SPPC-II SCRIPT Thank you for participating in the Safety Prog…

2030. Communication Strategies to Promote Resident Safety
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/communication-and-teamwork/communication-strategies.pptx
      September 01, 2016 - Communication Strategies to Promote Resident Safety Communication Strategies To Promote Resident Safety AHRQ Pub. No. 16-0003-13-EF September 2016 AHRQ Safety Program for Long-Term Care: CAUTI 1 Objectives After participating in the session, attendees will be able to— Identify possible barriers to effective com…

2031. Design Options for a Self-Management Support Program (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ptmgmt/design2.html
      July 01, 2018 - Patient Self-Management Support Programs: An Evaluation Design Options for a Self-Management Support Program (continued) Previous Page Next Page Table of Contents Patient Self-Management Support Programs: An Evaluation Acknowledgments Introduction and Purpose Summary Background Methodology…

2032. Best Practices in the Diagnosis and Treatment of Bacteremia (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/bacteremia-facilitator-guide.pdf
      November 01, 2019 - Best Practices in the Diagnosis and Treatment of Bacteremia AHRQ Safety Program for Improving Antibiotic Use 1 AHRQ Pub. No. 17(20)-0028-EF November 2019 Best Practices in the Diagnosis and Treatment of Bacteremia Acute Care Slide Title and Commentary Slide Number and Slide Best Pr…

2033. Meeting Minutes, November 2022 | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/events/nac/2022-11-nac/nacmtg111722-minutes.html
      July 01, 2023 - Meeting Minutes, November 2022 Virtual Meeting Minutes from the November 17, 2022, meeting of the Agency for Healthcare Research and Quality's National Advisory Council. Contents Summary Call to Order and Approval of July 21, 2022, Meeting Summary AHRQ Director’s Highlights Update on AHRQ Efforts to…

2034. Meeting Minutes, March 2021 | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/events/nac/2021-03-nac/nacmtg031821-minutes.html
      July 01, 2021 - Meeting Minutes, March 2021 Virtual Meeting Minutes from the March 18, 2021, virtual meeting of the Agency for Healthcare Research and Quality's National Advisory Council. Contents Summary Call to Order and Approval of November 10, 2020, Meeting Summary Recent AHRQ Accomplishments Update on AHRQ Bud…

2035. Systemwide Deployment of Medical Team Training: Lessons Learned in the Department of Defense (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/King.pdf
      January 01, 2002 - Systemwide Deployment of Medical Team Training: Lessons Learned in the Department of Defense 425 Systemwide Deployment of Medical Team Training: Lessons Learned in the Department of Defense Heidi B. King, Beth Kohsin, Mary Salisbury Abstract Advancing to a culture of safety requires a systems change. Teamw…

2036. 26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Simmons_66.pdf
      April 03, 2008 - 26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System 26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System Debora Simmons, RN, MSN, CCRN, CCNS; JoAnn Mick, PhD, RN, MBA, AOCN, CNAA, BC; Krisanne Graves, RN, BSN, CPHQ; Sharon K. Martin, ME…

2037. Physician Event Reporting: Training the Next Generation of Physicians (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
      May 01, 2003 - Physician Event Reporting: Training the Next Generation of Physicians 353 Physician Event Reporting: Training the Next Generation of Physicians Quang-Tuyen Nguyen, Joanna Weinberg, Lee H. Hilborne Abstract Physician reporting of adverse events and unsafe situations remains extremely low, despite the increa…

2038. Puh-Erepguide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-erepguide.docx
      February 10, 2014 - Pressure Ulcer Healing Reports AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing Facilitator Training Instructor Guide Slide 1: Introduction to Pressure Ulcer Healing Reports SAY: In this session we will introduce you to the pressure ulcer healing electronic reports. Slide 2: Pressure Ulcer H…

2039. Final Progress Report: Improving Medication Safety in Nursing Home Dementia Care (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/crystal-report.pdf
      January 01, 2024 - Final Progress Report: Improving Medication Safety in Nursing Home Dementia Care Title of Project: Improving Medication Safety in Nursing Home Dementia Care Principal Investigator: Stephen Crystal, Ph.D. Team Members: Stephen Crystal, Richard Hermida, Olga Jarrin, Marsha Rosenthal, Beth Angell, Sharon Cook, Shere…

2040. Final Progress Report: Developing an HIV-Specific Prevention Index Using the Electronic Medical Record (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/meenan-report.pdf
      January 01, 2025 - Final Progress Report: Developing an HIV-Specific Prevention Index Using the Electronic Medical Record 1  FINAL REPORT  Title:  Developing an HIV‐Specific Prevention Index Using the Electronic Medical Record  Principal Investigator: Richard T. Meenan, PhD, MPH, MBA, Center for Health Research ‐ Kaiser Permanente, …