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www.ahrq.gov/news/newsroom/case-studies/201507.html
April 01, 2015 - Memorial Hospital Uses AHRQ Resources to Cut Readmissions, Promote Patient Self-Management
Search All Impact Case Studies
April 2015
Memorial Hospital, a 97-bed community hospital in Marysville, Ohio, uses strategies from AHRQ's Re-Engineered Discharge (RED) toolkit to help newly discharged patients follo…
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www.ahrq.gov/sites/default/files/2024-04/ratliff-report.pdf
January 01, 2024 - Final Progress Report: Developing a patient-centered model of the risk of perioperative complications in spine surgery
Developing a patient-centered model of the risk of perioperative complications in spine surgery
John Ratliff, MD, PI
Team members:
Summer Han, PhD
Richard Olshen, PhD
Lu Tian, PhD
Paola Suarez
…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-19.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 4.19. Major Factors that Inhibit Lean Success
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Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
Case …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/sustainability/premortem-scorecard-slides.pptx
January 01, 2017 - Presentation: Tools for Sustainability: Premortem and Scorecard
Tools for Sustainability:
Premortem and Scorecard
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-39-EF
January 2017
Sustainability Tools ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
1
Learning Ob…
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www.ahrq.gov/sites/default/files/2024-01/minnitti-report.pdf
January 01, 2024 - Participants
were asked to analyze each step, identifying potential failures. … Although the FMEA did not yield a ranking of the key risks, the groups did
identify failures that could … As they identified those potential failures,
they began to share ideas for how to prevent or mitigate
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www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/redtool-30day.html
March 01, 2013 - Re-Engineered Discharge (RED) Toolkit
How CMS Measures the "30-Day All Cause Rehospitalization Rate" on the Hospital Compare Web Site
Previous Page Next Page
Table of Contents
Re-Engineered Discharge (RED) Toolkit
Tool 1: Overview
Tool 2: How To Begin the Re-engineered Discharge Implementation a…
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www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool-30day.html
March 01, 2013 - Re-Engineered Discharge (RED) Toolkit
How CMS Measures the "30-Day All Cause Rehospitalization Rate" on the Hospital Compare Web Site
Previous Page Next Page
Table of Contents
Re-Engineered Discharge (RED) Toolkit
Tool 1: Overview
Tool 2: How To Begin the Re-engineered Discharge Implementation a…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Browne_5.pdf
January 20, 2008 - “Active
failures” are unsafe acts
committed by people who
are in direct contact with
the patient … “Latent
conditions” are the
inevitable systems failures,
that relate to design—such as alarms that
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/sppcii-module-handouts.docx
July 01, 2023 - Implementation Module Handouts
Implementation Module Handouts
Use these handouts to help your team implement the Safety Program in Perinatal Care. For each tool, follow the actions listed to develop information to fill in the tables.
Hospital AIM Team Staff List
Actions:
Select members for a multidisciplinary Hospit…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab14.html
February 01, 2023 - Assessing the Health and Welfare of the HCBS Population
Table 14A: Outcome Indicators by County Supply of Health Care Providers
Previous Page Next Page
Table of Contents
Assessing the Health and Welfare of the HCBS Population
Introduction
HCBS Population
Availability and Use of State Medicaid …
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-2.html
June 01, 2020 - Measurement should not be used punitively to identify provider failures but rather should be used to
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www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chap5tab22.html
December 01, 2017 - Table 22. Indian Health Service total treatment cost estimates a by health status. All project sites. Fiscal year 2010
ARRA Grants Initiative
Findings from a set of 16 grants on improving delivery systems and on spreading evidence-based practices through delivery systems; recommendations and methods for advan…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/hopkinsinternalmed-slides.ppt
January 01, 2013 - Slide 1
Algorithm driving ‘smart’ order set at Hopkins in Medical inpatients
Zeidan AM, et al. Am J Hematol. 2013; 88:545-549
Major Risk Factors
Age > 60
Cancer
Previous VTE
Acute CVA w/ paresis (< 3 mos.)
Thrombophilia
Decompensated NYHA Class III/IV
heart failure
Respiratory failure (ventilator-dependent)
…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Baker_107.pdf
March 30, 2008 - Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems
Analysis of Patient Safety: Converting Complex
Pediatric Chemotherapy Ordering Processes
from Paper to Electronic Systems
Donald K. Baker, PharmD; James M. Hoffman, PharmD; Gregory A. Hal…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0129references.pdf
October 23, 2013 - References
1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the
Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418–1428.
2. Wick EC, Shore AD, Hirose K, Ibrahim AM, Gearhart SL, Efron J, Weiner JP, Makary MA.
Readmission rates and cost following colorectal surgery. Dis …
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/002-cusp-learning-defects.pptx
October 01, 2024 - The impact of operational failures on hospital nurses and their patients.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
April 01, 2025 - The impact of operational failures on hospital nurses and their patients.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b4_combo_documentationcoding.pdf
March 15, 2016 - Documentation and Coding for Patient Safety Indicators
Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
Tool B.4 i
Documentation and Coding for the AHRQ Quality Indicators
Note: This tool was updated based on test software provided by AHRQ as of March 2016 (alpha
version…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0231-fullreport.pdf
May 01, 2018 - Timely Fluid Bolus for Children With Severe Sepsis or Septic Shock
1
Timely Fluid Bolus for Children with Severe Sepsis or
Septic Shock
Section 1. Basic Measure Information
1.A. Measure Name
Timely Fluid Bolus for Children with Severe Sepsis or Septic Shock
1.B. Measure Number
0231
1.C. Measure Descript…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/sampleransferandintakenotes.pdf
June 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time
Preventable Hospital and Emergency Department Visits
Transfer Note and Intake Note
Transfer Notes and Intake Notes are not required, but the elements included in them must be in
the nursing home’s electronic medical record (EMR) to generate all components of the re…