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1661. Final Progress Report: Implementing a Program of Patient Safety in Small, Rural Hospitals (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/jones-report.pdf
      January 01, 2024 - Final Progress Report: Implementing a Program of Patient Safety in Small, Rural Hospitals Implementing a Program of Patient Safety in Small, Rural Hospitals Principal Investigators Katherine J. Jones, PhD, PT, January 2007 – June 20071 Keith J. Mueller, PhD, July 2005 – December 20061 Team Members Anne Skinn…

1662. Learn From Defects Tool—Perioperative Setting | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/learn-from-defects.html
      December 01, 2017 - Learn From Defects Tool—Perioperative Setting AHRQ Safety Program for Surgery What is a defect? A defect is any event or situation that you don’t want to repeat. This could include an incident that caused patient harm or put patients at risk for harm, such as a patient fall. Problem statement: …

1663. EvidenceNOW Southwest Practice Survey (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/practice-survey-6mon-post-intervention-sw.pdf
      April 03, 2017 - Patients with care or outcomes falling outside of guidelines are identified for more intensive care.

1664. Final Progress Report: A National Report of Nursing Home Quality Measures and Information Technology (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/alexander-report.pdf
      January 01, 2024 - Depressive Symptoms 14168 797 5.6 5.1 Who Were Physically Restrained 14203 798 0.9 0.7 One or More Falls … 0.04 Who Were Physically Restrained -0.02 -0.02 0.01 0.01 0.01 0.01 0.01 0.00 -0.02 0.00 One or More Falls

1665. Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
      January 29, 2008 - • Monitoring errors, such as bedsores, failure to rescue, and patient falls.

1666. Enhancing Safety for Patients with Limited English Proficiency Train-the-Trainer Instructor Guide
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/traintrainers/lepigstafftrain.pptx
      November 19, 2008 - A clinical example would be an information call-out such as, “BP is falling, 80/48 down from 90/60.”

1667. Health Literacy: Making It Easier for Patients to Find, Understand, and Use Health Information and Services (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/health-literacy/3rd-edition-toolkit/health-literacy-education-presentation-tool-3a.pdf
      January 01, 2019 - And we rarely follow up to make sure that they are not falling between the cracks.

1668. Documentation of Mandated Discharge Summary Components in Transitions from Acute to Subacute Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Kind_31.pdf
      March 31, 2008 - Falling through the cracks: Challenges and opportunities for improving transitional care for persons

1669. TeamSTEPPS 2.0 Module 9: Coaching Workshop
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule9.pptx
      April 10, 2006 - If the exercise falls before break, introduce the exercise and hand out the ASTD coaching self-assessment

1670. 2018 National Healthcare Quality and Disparities Report: Introduction and Methods (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-intro-methods.pdf
      September 01, 2019 - continue to be collected and these measures will be added back to the report if their performance falls

1671. 3. Breadth and Focus Areas of Federal Agency Research Portfolios in HSR and PCR | Agency for Healthcare Research and Quality
      www.ahrq.gov/healthsystemsresearch/hspc-research-study/breadth-and-focus.html
      July 01, 2021 - Although much of this research falls outside the scope of this study, federal and other stakeholders

1672. SOPS™ 101 Webcast Transcript (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops101-webcast-transcript.pdf
      June 01, 2020 - SOPS™ 101 Webcast Transcript November 2018 https://www.ahrq.gov/sops/index.html 1 Understanding SOPS Surveys: A Primer for New Users October 23, 2018 – Webcast Transcript Speakers: Laura Gray, M.P.H. Senior Study Director User Network for the AHRQ Surveys on Patient Safety C…

1673. Understanding SOPS Surveys: A Primer for New Users (Webcast) Transcript (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/SOPS101_Webcast_Transcript.pdf
      June 01, 2022 - Understanding SOPS Surveys: A Primer for New Users (Webcast) Transcript Understanding SOPS Surveys: A Primer for New Users February 19, 2020 – Webcast Transcript Speakers: Naomi Yount, Ph.D. Senior Study Director User Network for the AHRQ Surveys on Patient Safety Culture (SOPS), Westat (Moderator) Laura Gra…

1674. Webinar Transcript - National Quality Strategy Webinar: Using the Nine Levers to Achieve Results | Agency for Healthcare Research and Quality
      www.ahrq.gov/workingforquality/events/webinar-using-the-nine-levers-to-achieve-results.html
      November 01, 2016 - Webinar Transcript - National Quality Strategy Webinar: Using the Nine Levers to Achieve Results August 19, 2014 Download accessible version of slides (PDF, 2.4 MB) National Quality Strategy Webinar: Using the Nine Levers to Achieve Results [Slide 1] Ann Gordon:  Good afternoon everyone. We want to…

1675. Final Progress Report: National Trends in Outpatient Quality Indicators (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/stafford-fortmann-report.pdf
      January 01, 2024 - Final Progress Report: National Trends in Outpatient Quality Indicators Final Report: National Trends in Outpatient Quality Indicators September 27, 2006 Principal Investigator Randall Stafford, MD, PhD Team Members Stephen Fortmann, Co-investigator Helena Kraemer, Statistician Marilyn Winkleby, Advisory Board M…

1676. Final Progress Report: Exploratory Study Using Queuing Theory To Improve Nurse Staffing Effectiveness (pdf file)
      www.ahrq.gov/sites/default/files/2024-10/stone-report.pdf
      January 01, 2024 - Final Progress Report: Exploratory Study Using Queuing Theory To Improve Nurse Staffing Effectiveness Title: Exploratory Study Using Queuing Theory to Improve Nurse Staffing Effectiveness Principal Investigator Patricia W. Stone Team Members: Linda Green Haomiao Jia Pam de Cordova Sookyung Hyun Stephanie Goldbe…

1677. Final Progress Report: Determinants of Intrapartum Quality of Care (pdf file)
      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 …

1678. Final Progress Report: Developing a Framework to Study and Improve Communication to Enhance Diagnostic Quality in the ED (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/mahajan-manojlovich-report.pdf
      January 01, 2025 - Information flow during pediatric trauma care transitions: things falling through the cracks.

1679. CHIPRA 119 Section 5, Literature Review and Discussion (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-119-section-5-lit-review.pdf
      March 19, 2012 - normal range of 36.5° C to 37.5 °C (skin temperature of 0.5° C to 1.0° C lower) When skin temperature falls … bonnet may result in hyperthermia but only when metabolic heat production rises while skin temperature falls … When skin temperature falls to 35° C to 36° C, non-shivering thermogenesis is initiated (Bruck 1961)

1680. Hemoglobin S Monitoring Prior to Chronic Transfusion Among Children With Sickle Cell Anemia (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-214-fullreport.pdf
      February 01, 2019 - The measure highlights where providers or health systems are falling short in providing health care … When the oxygen supply to the brain falls below a critical level based on need, brain dysfunction occurs