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psnet.ahrq.gov/issue/roadmap-advance-patient-safety-ambulatory-care
June 09, 2021 - September 13, 2023
Information flow during pediatric trauma care transitions: things falling
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psnet.ahrq.gov/issue/systematic-review-human-factors-and-ergonomics-hfe-based-healthcare-system-redesign-quality
February 13, 2014 - January 20, 2021
Information flow during pediatric trauma care transitions: things falling
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psnet.ahrq.gov/issue/factors-associated-diagnostic-error-analysis-closed-medical-malpractice-claims
July 13, 2022 - October 25, 2017
WebM&M Cases
Falling Between the Cracks
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www.ahrq.gov/patients-consumers/diagnosis-treatment/treatments/btpills/btpills.html
March 01, 2023 - Blood Thinner Pills: Your Guide to Using Them Safely
The Agency for Healthcare Research and Quality offers a free booklet and a video about blood thinner medicines. Staying Active and Healthy with Blood Thinners , a 10-minute video, features easy-to-understand explanations of how blood thinners wor…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/2-preventablehospitalandedvisits-samplerpts_3.pdf
November 30, 2013 - pulmonary disease
• Asthma
• Circulatory problems
• Hypertension
• Gastroenteritis
• Angina pectoris
• Falls … obstructive
pulmonary disease, asthma, circulatory problems, hypertension, gastroenteritis, angina,
falls
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digital.ahrq.gov/ahrq-funded-projects/rural-iowa-redesign-care-delivery-ehr-functions/citation/redesigning-care
January 01, 2023 - Redesigning care delivery through health IT implementation. Exploring Trinity Health's IT model.
Citation
Crandall DK, Brokel JM, Schwichtenberg T, et al. Redesigning care delivery through health IT implementation. Exploring Trinity health's IT model. J Healthc Inf Manag 2007 Fall;21(4):41-8.
L…
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digital.ahrq.gov/ahrq-funded-projects/evaluation-and-integration-automatic-fall-prediction-system/citation/tracking
January 01, 2023 - Tracking natural human movements identifies differences in cognition and health.
Citation
Kearns WD, Fozard JL. Tracking natural human movements identifies differences in cognition and health. In: Augusto JC, Huch M, Kameas A, et al, eds. Handbook of ambient assisted living-technology for healthcare, …
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psnet.ahrq.gov/node/41070/psn-pdf
January 18, 2012 - Confirmation bias: why psychiatrists stick to wrong
preliminary diagnoses.
January 18, 2012
Mendel R, Traut-Mattausch E, Jonas E, et al. Confirmation bias: why psychiatrists stick to wrong
preliminary diagnoses. Psychol Med. 2011;41(12):2651-2659. doi:10.1017/S0033291711000808.
https://psnet.ahrq.gov/issue/confirm…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-reimagining-healthcare-teams.pdf
July 07, 2023 - process hundreds of thousands of heartbeats in seconds22, 23 and
others that can automatically track falls … ensuring the technology is worn, while the AI
would provide daily summaries about fall risk and near falls … This information could lead to interventions to prevent falls. … Automated loss-of-balance event identification in older adults at
risk of falls during real-world walking
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digital.ahrq.gov/ahrq-funded-projects/medication-metronome-project
January 01, 2023 - However, national and local data indicate that the United States health care system is falling significantly
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digital.ahrq.gov/ahrq-funded-projects/using-evidence-based-nursing-practices-and-electronic-health-record-decision-1
January 01, 2023 - Specifications for a quality improvement (QI) clinical decision support (QI-CDS) tool (Chapter 3; Figures 11-12; Appendix K)
Citation
Specifications for a quality improvement (QI) clinical decision support (QI-CDS) tool (Chapter 3; Figures 11-12; Appendix K)
PDF
Specifications for a qual…
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digital.ahrq.gov/ahrq-funded-projects/long-term-effectiveness-telephone-intervention-problem-solving-tips/citation/long-term
January 01, 2023 - The long-term effects of cellular telephone-delivered telephone intervention problem solving (TIPS) for schizophrenia spectrum disorders (SSDs): rationale and design.
Citation
Beebe LH, Smith K, Phillips C, et al. The long-term effects of cellular telephone-delivered telephone intervention problem so…
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digital.ahrq.gov/ahrq-funded-projects/shareable-interoperable-clinical-decision-support-older-adults-advancing-fall/citation/experts
January 01, 2023 - Experts' perspectives on use of fast healthcare interoperable resources for computerized clinical decision support.
Citation
Shear K, Horgas AL, Lucero R. Experts' perspectives on use of Fast Healthcare Interoperable Resources for computerized clinical decision support. Comput Inform Nurs. 2023 Jul 11…
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effectivehealthcare.ahrq.gov/sites/default/files/s77.pdf
October 01, 2007 - Low-Income Assistance
The VA allows veterans to receive a waiver of copay-
ment if the veteran’s income falls … assuming all brand name usage and no
prescription fills for longer than a month, the average cost
savings falls
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psnet.ahrq.gov/web-mm/moving-pains
August 17, 2017 - What is the expected level of intervention (eg, replace an oxygen mask if it falls off, silence an IV … July 31, 2023
Patient Safety Innovations
Preventing Falls
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/06-sops-teamstepps-webcast-closing.pdf
January 01, 2022 - Enhancing Surgical Team Communication: SOPS® and TeamSTEPPS®in Action Webcast - Closing
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EVALUATION
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U.S. STUDIES USING TEAMSTEPPS AND SOPS
Bilello,…
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www.ahrq.gov/cahps/surveys-guidance/hospital/about/dev_adult_hp_survey.html
January 01, 2025 - Development of the CAHPS Adult Hospital Survey
The CAHPS Hospital Survey was conceived first and foremost as a tool for public reporting purposes. While many hospitals already conduct some type of patient survey, CMS needed a standardized instrument that would allow consumers to compare inpatients' perspectiv…
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digital.ahrq.gov/principal-investigator/mcalearney-ann-scheck
January 01, 2023 - McAlearney, Ann Scheck
Understanding secure messaging in the inpatient environment: a new avenue for communication and patient engagement.
Citation
Sieck CJ, Walker DM, Hefner JL, et al. Understanding secure messaging in the inpatient environment: a new avenue for communicati…
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www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/chsp-compendium-2020-rev.csv
January 01, 2020 - 23995 95.71 0 0 0 1 0 0 1 1 1 0 1 H3664 17089 1 657702498 1635297208
HSI00000068 Avera Health Sioux Falls … 1 0 1 97 3806 0 0 0 0 0 0 0 0 1 224436877 942200800
HSI00000107 Benefis Health System Great Falls … 60 21 39 8 21 1 1 0 1 50 3062 0.12 0 0 0 1 0 0 0 0 0 0 0 1 199137437 946433391
HSI00000401 Glens Falls … 5 4 1 1 799 37917 11.19 0 0 0 1 0 0 1 1 659321994 2029599905
HSI00000513 Inova Health System Falls … Memorial Medical Center Niagara Falls NY 1 0 18407987 56 25 18 16 14 1 1 1 1 133 4470 16.9 0 0 0 1
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www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/chsp-compendium-2020-rev.xlsx
January 01, 2020 - 23995 95.71 0 0 0 1 0 0 1 1 1 0 1 H3664 17089 1 657702498 1635297208
HSI00000068 Avera Health Sioux Falls … 1 0 1 97 3806 0 0 0 0 0 0 0 0 1 224436877 942200800
HSI00000107 Benefis Health System Great Falls … 60 21 39 8 21 1 1 0 1 50 3062 0.12 0 0 0 1 0 0 0 0 0 0 0 1 199137437 946433391
HSI00000401 Glens Falls … 5 4 1 1 799 37917 11.19 0 0 0 1 0 0 1 1 659321994 2029599905
HSI00000513 Inova Health System Falls … Memorial Medical Center Niagara Falls NY 1 0 18407987 56 25 18 16 14 1 1 1 1 133 4470 16.9 0 0 0 1