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2001. From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Kravitz.pdf
      February 09, 2005 - From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator 395 From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator Richard L. Kravitz, Jonathan D. Neufeld, Michael A. Hogarth, Debora A. Paterniti, William Dager, …

2002. Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Woods_78.pdf
      July 23, 2008 - Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions Donna M. Woods, EdM, PhD; Jane L. Holl, MD, MPH; Denise Angst, PhD, RN; Susan C. Echiverri, MD; Daniel Johnson, MD; David F. Soglin, MD; Gop…

2003. Measuring IT Sophistication in Nursing Homes (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Alexander_10.pdf
      January 20, 2008 - Measuring IT Sophistication in Nursing Homes Measuring IT Sophistication in Nursing Homes Gregory L. Alexander, PhD, RN; Dick Madsen, PhD; Stephanie Herrick; Brady Russell Abstract Objective: Little activity has occurred in nursing home (information technology) IT adoption. The purpose of this study was to de…

2004. Development of a Comprehensive Medical Error Ontology (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Mokkarala_103.pdf
      June 16, 2008 - Development of a Comprehensive Medical Error Ontology Development of a Comprehensive Medical Error Ontology Pallavi Mokkarala, MS; Julie Brixey, RN, PhD; Todd R. Johnson, PhD; Vimla L. Patel, PhD; Jiajie Zhang, PhD; James P. Turley, RN, PhD Abstract A critical step towards reducing errors in health care …

2005. Six Building Blocks How-To-Implement Toolkit: Fast Track Approach Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/ambulatory/6bb-toolkit-fasttrack.pdf
      January 12, 2021 - Six Building Blocks How-To-Implement Toolkit: Fast Track Approach Guide A Team-Based Approach to Improving Opioid Management in Primary Care Table of Contents Introduction ......................................................................................................................................1 W…

2006. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
      August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Issue Brief 8 Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department PATIENT SAFETY e This page intentionally left blank. e Issue Brief 8 Distributed Cognition and the Rol…

2007. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
      www.ahrq.gov/sites/default/files/publications2/files/distributed-cognition-er-nurses_0.pdf
      August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Issue Brief 8 Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department PATIENT SAFETY e This page intentionally left blank. e Issue Brief 8 Distributed Cognition and the Rol…

2008. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
      June 30, 2004 - Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative 133 Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative Daniel M. Harris, John M. Westfall, Douglas H. Fernald, Christine W. Duclos, David R. West, Linda Niebauer, Linda Ma…

2009. Metabolic Monitoring for Children and Adolescents on Antipsychotics (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-150-fullreport.pdf
      February 14, 2018 - Metabolic Monitoring for Children and Adolescents on Antipsychotics 1 Metabolic Monitoring for Children and Adolescents on Antipsychotics Section 1. Basic Measure Information 1.A. Measure Name Metabolic Monitoring for Children and Adolescents on Antipsychotics 1.B. Measure Number 0150 1.C. Measure Descripti…

2010. Care Coordination Quality Measure for Primary Care (CCQM-PC) - Development and Pilot Test of the CCQM-PC (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/ccqmpc/ccqmp-pc-development.pdf
      July 01, 2016 - Care Coordination Quality Measure for Primary Care (CCQM-PC) - Development and Pilot Test of the CCQM-PC Care Coordination Quality Measure for Primary Care (CCQM-PC) Development and Pilot Test of the CCQM-PC v 1.0; Guidance for Use of CCQM-PC v 2.0 Overview of the Care Coordination Quality Measure…

2011. 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/lepigtrainer.pptx
      July 01, 2012 - A clinical example would be an information call-out such as, “BP is falling, 80/48 down from 90/60.”

2012. Train-the-Trainer Instructor Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps/lep/traintrainers/lepigtrainer.html
      October 01, 2020 - A clinical example would be an information call-out such as, "BP is falling, 80/48 down from 90/60."

2013. Conflict Resolution (Transcript) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/conflict.html
      April 01, 2013 - The patient definitely is volume-depleted, and he definitely has saturation falling, and I think it’s

2014. CLABSI Investigation Process: Walk the Process (Transcript) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/clabsi-invest.html
      April 01, 2013 - worked on that are there for everybody to use in order to look to see where in the process things are falling

2015. Timeliness of Antibiotic Prophylaxis for Children With Sickle Cell Disease (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-135-fullreport.pdf
      February 01, 2017 - The measure highlights where providers or health systems are falling short in providing this essential

2016. Appendix A. Grantee Profiles | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/capacity/candor/demo-program/plan-grants/appa.html
      May 01, 2016 - Sioux Falls, SD; December 2011:16. Pichert JW, Hoffman WW, Danielson D, et al.

2017. TeamSTEPPS 2.0 Module 6: Mutual Support
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule6.pptx
      February 09, 2006 - She's a pharmacist with the office of the Army Surgeon General in Falls Church, Virginia. Ms.

2018. Appendix A. Grantee Profiles | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/appa.html
      August 01, 2022 - Sioux Falls, SD; December 2011:16. Pichert JW, Hoffman WW, Danielson D, et al.

2019. Communication: Severe Hypertension - PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_3_communication.pptx
      July 01, 2023 - response to treatment Safety: Critical lab values/reports, socioeconomic factors, allergies, and alerts (falls

2020. Communication: Severe Hypertension (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_3-communication-speaker-notes.pdf
      July 01, 2023 - treatment • Safety: Critical lab values/reports, socioeconomic factors, allergies, and alerts (falls