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341. Final Progress Report: Patient Safety in Hospice Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/smucker-report.pdf
     January 01, 2024 - Almost no effort has been given to understanding the prevention of patient safety incidents in the growing … (Specific Aim 3: Opportunities for prevention) 6. … Description of detection/prevention/mitigating factors: What are the “actions or circumstances” within … The interview guide included prompts to explore possible detection, mitigation, and prevention opportunities

342. Methodological Challenges in Describing Medication Dosing Errors in Children (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/McPhillips.pdf
     January 01, 2004 - he or she meant to prescribe), potentially no error would be detected because this dose would still fall … Many minimum recommended adult doses fall well below the minimum recommended weight-based dose for … Implications for prevention. ADE Prevention Study Group. JAMA 1995;274(1):29–34. 2. … Medication error prevention by clinical pharmacists in two children’s hospitals. … The impact of computerized physician order entry on medication error prevention.

343. Technical Interventions To Prevent CAUTI | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/guides/implguide-pt3.html
     October 01, 2015 - Infographic Poster on CAUTI Prevention Appendix L. … One effective way to gain the support of patients and their family members in CAUTI prevention efforts … team can use to begin the CAUTI prevention journey with the staff. … Teams that set goals, make progress toward goals, and then reach their CAUTI prevention goals should … staff to follow evidence-based CAUTI prevention practices in three domains: appropriate catheter use

344. Engaging-Nurse-Physician-Patient-Transcript (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/engaging-nurse-physician-patient-transcript.docx
     June 02, 2025 - To really get their attention present on the business case for CAUTI prevention. … in CAUTI prevention? … This second example was from a few weeks ago after a patient fall. … These learn from a defect, or super falls huddles, take place very quickly after a fall. … In this case the patient did already have some fall prevention tactics in place, but we did identify

345. Session 2 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod1sess2.html
     October 01, 2014 - The resident may have had a fall and may have a broken bone or have worsening arthritis with increased … Falls Risk A fall is defined as "involuntarily coming to rest on a lower surface," whether it is an … There are many things that can cause a fall, including things in the environment (like lighting, slippery … have difficulty breathing at night due to chronic lung problems, snoring, or pneumonia and may never fall … Falls —Watch the resident when doing things that could result in a fall (e.g., reaching for objects when

346. Workplace Safety Resource List (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/workplace-safety/workplace_safety_resource_list.pdf
     October 01, 2021 - Centers for Disease Control and Prevention (CDC) Resources a. … Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus … /physician-health/bullying-health-care- workplace-guide-prevention-mitigation The guide provides the … Employers should use these guidelines to develop appropriate workplace violence prevention programs, … Program Workplace Violence Prevention Workplace Violence Prevention for Nurses Improving Workplace

347. Final Progress Report: SAFER: Standardizing Admissions for Elderly residents (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/coburn-report.pdf
     January 01, 2024 - The project resulted in an online infection control and prevention training module that is currently … After the completion of the evaluation this fall, the curriculum will be offered to other state EMS … Project Closeout Reports: Each pilot site project completed a survey in the fall of 2012 to summarize … EMS online training An online infection control and prevention training curriculum for EMS providers … Manuscript on the EMS intervention and online training tool to be submitted to a peer-reviewed publication, Fall

348. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/build-businesscase-facguide.docx
     January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle Slide Title and Commentary Slide Number and Slide

349. AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Functional Specifications (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/functspecs.pdf
     March 22, 2014 - ulcer healing, falls prevention, and prevention of inappropriate hospitalizations. … Specifications for Each Pressure Ulcer Prevention Report 3.1. … for Nursing Homes: On-Time Pressure Ulcer Prevention 12 3.2.4. … Days Prior value may not be the same as Weight for Week 4 because the 30 Days Prior value date may fall … 30 Days Prior value may not be the same as Weight for Week (Week4) because 30 Days Prior value may fall

350. Potential Measures | Agency for Healthcare Research and Quality
     www.ahrq.gov/prevention/resources/chronic-care/ccrm-atlas-suppl/ccrm-atlas3.html
     October 01, 2013 - clinician) K Patient has a usual source of primary care L Patient ability to achieve prevention … of care with primary care clinic/clinician HH Clinician supports patient self-management of prevention … II Patient report of shared decision making regarding prevention JJ Utility of “bridging … RR Prevention goal setting and action planning SS Communication between client and community … engage and interact with patients ZZ Community resource supports patient self-management of prevention

351. Halpern, Scott | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumhalp.html
     October 01, 2014 - Future Plans: Data collection will continue through the summer and fall and the clinician interview

352. Module 2: How To Manage Change | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides2.html
     October 01, 2017 - (Tool 2C) Present the assessment of current pressure injury prevention policies and procedures. … Slide 5: Expected Outcomes Begin to write a draft Pressure Injury Prevention Action Plan, tailored … Members who influence the areas involved in pressure injury prevention. … Slide 10: QI Process Link the Pressure Injury Prevention Program with quality improvement. … Slide 24: Sample Action Plan Images: Two screenshots show an example of a Pressure Ulcer Prevention

353. Unique Challenges in Approaching Diagnostic Safety in Older Adults | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults2.html
     September 01, 2024 - Recent research from the Centers for Disease Control and Prevention suggests that about 10 percent of

354. Engaging the Nurse, Physician, Patient/Family, CUSP: Learn From Defects | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/engaging-nurse-physician-patient-transcript.html
     December 01, 2017 - To really get their attention present on the business case for CAUTI prevention. … in CAUTI prevention? … This second example was from a few weeks ago after a patient fall. … These learn from a defect, or super falls huddles, take place very quickly after a fall. … In this case the patient did already have some fall prevention tactics in place, but we did identify

355. Reducing Unecessary Urinary catheter Use in the Emergency Department: How to Implement the Process (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-091013.ppt
     January 01, 2010 - In prevention of CAUTI, this communication is vital. Discuss the indications.

356. Epidemiology of Invasive Devices and Complications | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/phys-championsgd/section2.html
     October 01, 2015 - Mechanical complications include urethral trauma, hematuria, immobility, and fall risk.

357. Leveraging Cultural Change to Reduce Urinary Catheter Use | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/leveraging-cultural-change-slides.html
     December 01, 2017 - Leveraging Cultural Change to Reduce Urinary Catheter Use Linda Greene, RN,MPS,CIC Manager Infection Prevention … She’s going to fall trying to get up.”

358. Small and Rural and Critical Access Hospitals (Transcript) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/content-calls/small-hospitals.html
     April 01, 2013 - re going to listen first to Denise Flook, who is the director of workforce development and infection prevention … I work especially with our patient safety on infection prevention initiatives, and Lorna Martin works … We want to enhance the coordination of care because that’s where a lot of times we fall down. … What is your fall rate or your pressure ulcer rate or whatever? … Or, “We’ve gone 20 days without a patient fall.”

359. Preventing CAUTI: What to Do When it’s Time for Plan B (November 4, 2014) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/preventing-cauti-plan-b-transcript.html
     December 01, 2017 - We had seven hospitals that were implementing a CAUTI prevention program. … This is actually a CAUTI prevention guide to patient safety. … Do you have a project manager with dedicated time coordinate your CAUTI prevention activities? … prevention on that same unit? … This has to do in applying mindfulness to CAUTI prevention.

360. Examples of Physician Quality Measures for Consumers | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/measures/setting/physician/examples.html
     September 01, 2019 - Examples of Physician Quality Measures for Consumers Following are a few examples of physician quality measures that research evidence and practical experience suggest are appropriate for reporting to consumers. The list is categorized by the Institute of Medicine’s domains for a quality health care system; for…