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  1. www.ahrq.gov/practiceimprovement/delivery-initiative/casalino/paper/idkeydsrapc.html
    February 01, 2014 - Identifying Key Areas for Delivery System Research Appendix C: "Long List" of Delivery System Research Areas Previous Page Next Page Table of Contents Identifying Key Areas for Delivery System Research Executive Summary Identifying Key Areas for Delivery System Research Conclusion References…
  2. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
    April 01, 2025 - Learning From Defects Learning From Defects Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries AHRQ Pub. No. 25-0029 April 2025 AHRQ Safety Program for MRSA Prevention: Targeting SSI AHRQ Safety Program for MRSA Prevention | Surgical Services Learning From Defects 1 Educat…
  3. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
    December 23, 2004 - Figure 3 presents human error, and the organizational and environmental enabling factor classifications
  4. www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P1O-Comprehensive_Antibiogram_Toolkit_Phase_1_Assessment_and_Planning_final.pdf
    May 01, 2014 - The ability of the laboratory to generate a complete antibiogram report will be a key factor in advancing
  5. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-4.html
    September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science Research Agenda Previous Page Next Page Table of Contents The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Chi…
  6. www.ahrq.gov/research/findings/final-reports/index.html
    September 01, 2024 - Grantee Final Reports: Patient Safety Final reports from research grants administered since 2000 on a variety of patient safety topics, such as measure development, medication safety, and diagnostic safety. The Agency for Healthcare Research and Quality Center for Quality Improvement and Patient Safety subdivis…
  7. www.ahrq.gov/patient-safety/resources/learning-lab/design-environments-long-desc.html
    April 01, 2021 - Institute for the Design of Environments Aligned for Patient Safety (IDEA4PS) Principal Investigators: Ann Scheck McAlearney, Sc.D., M.S., The Ohio State University, Columbus, OH; formerly Susan Moffatt-Bruce, M.D., Royal College of Physicians and Surgeons of Canada, Ottawa AHRQ Grant No.: HS024379 Proj…
  8. www.ahrq.gov/sites/default/files/2024-12/bailit-aron-love-report.pdf
    January 01, 2024 - Final Progress Report: Determinants of Intrapartum Quality of Care Determinants of Intrapartum Quality of Care Jennifer Bailit MD, MPH David Aron, MD Thomas Love, PhD Case Western Reserve University 9/30/05-9/29/07 Project Officer: Judith Sangl This project was supported by grant number 5 R03 HS014352 from …
  9. TO (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d8_combo_projectevaluation.docx
    June 02, 2025 - TO Project Evaluation and Debriefing What is the purpose of this tool? The purpose of the project evaluation is to: Identify factors that contributed to the team’s success. Identify factors that hindered the team’s success. Identify additional clinical areas in the organization where the best practice can be implemen…
  10. www.ahrq.gov/research/findings/final-reports/iomracereport/reldata1fig12txt.html
    April 01, 2018 - Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement Figure 1-2: Williams, Lavizzo-Mourey, and Warren's framework for under Previous Page Next Page Table of Contents Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement Summary …
  11. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/choosing/choosing.doc
    June 02, 2025 - Choosing Quality Measures Choosing Quality Measures Contents Some Planning Suggestions · Think Long Term · Consider All Available Measurement Tools · Think Fewer Measures · Develop a Plan Factors to Consider · Making Comparisons · Databases and Benchmarks · Trends Over Time · Service Delivery Systems · Unit of Ana…
  12. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/002-cusp-learning-defects.pptx
    October 01, 2024 - AHRQ Safety Program for MRSA Prevention AHRQ Safety Program for MRSA Prevention Learning From Defects ICU & Non-ICU AHRQ Pub. No. 25-0007 October 2024 AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU Learning From Defects 1 Educational Objectives Describe a process to help teams learn from defects Explore …
  13. www.ahrq.gov/sites/default/files/2024-09/studdert-report.pdf
    January 01, 2024 - implement a series of targeted patient safety interventions based on results from the contributing factor
  14. www.ahrq.gov/research/findings/final-reports/index.html?page=8
    January 01, 2024 - Grantee Final Reports: Patient Safety Final reports from research grants administered since 2000 on a variety of patient safety topics, such as measure development, medication safety, and diagnostic safety. The Agency for Healthcare Research and Quality Center for Quality Improvement and Patient Safety subdivis…
  15. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
    January 01, 2017 - deeper as you identify contributing factors Use the “5 Whys” technique Why 1—Why did this contributing factor
  16. www.ahrq.gov/hai/tools/mvp/modules/cusp/science-of-safety-fac-guide.html
    February 01, 2017 - Science of Safety and Identifying Defects in Care of Mechanically Ventilated Patients: Facilitator Guide AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: Science of Safety and Identifying Defects in Care of Mechanically Ventilated Patients Say: Today, we will give you an overview of the…
  17. www.ahrq.gov/sites/default/files/wysiwyg/chsp/chsp-fact-sheet-0717.pdf
    October 01, 2016 - AHRQ Comparative Health System Initative Comparative Health System Performance Initiative The Agency for Healthcare Research and Quality (AHRQ) created the Comparative Health System Performance Initiative to study how health care systems promote evidence-based practices in delivering care. The initiative provid…
  18. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-facguide.docx
    January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle Slide Title and Commentary Slide Number and Slide Title Slide Science of Safety and Identifying Defects in Care of Mechanically Ventilated Patients SAY: Today, we will give you an overview of the Science of Safety and identifying defects. Slide 1 Learning O…
  19. www.ahrq.gov/talkingquality/explain/support/help.html
    November 01, 2018 - Help People Use Health Care Quality Information To Make Decisions Some members of your audience will have a good idea of how to go about using quality information to make a decision about a health provider or plan, but others will not. You can help the latter group: Clarify to what extent they have a choice…
  20. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereportguide.html
    September 01, 2017 - Rule 1 : High risk based on prior hospital or ED visit AND an existing high-risk factor Criteria … : Resident has prior hospital or ED visits in last 90 days and at least one additional risk factor … Polypharmacy is considered the use of 15 or more medications and is treated as a risk factor for hospital … This score can indicate the severity of the risk factor and the likeliness that this condition could … This score can indicate the severity of the risk factor and the likeliness that this condition could

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