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4701. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867850/psn-pdf
      February 26, 2025 - high reliability approaches are associated with things like fewer medication errors, fewer patient falls … And the source of both becoming highly reliable and falling apart was leadership.

4702. Jun-2017-Cholesterol-Wg-Notes (doc file)
      cds.ahrq.gov/sites/default/files/workgroups/241/jun-2017-cholesterol-wg-notes.docx
      January 01, 2017 - Cholesterol Management Work Group Meeting Summary Date 06/21/2017 Time 1:30 – 2:45 PM EST AGENDA · Welcome and Review of Agenda · Gather Feedback on Additional Details Required to Support Development of the eCQM Artifact · Next Steps and Closing · SUMMARY Welcome CAMH welcomed the WG Members to the Jun…

4703. Using the AHRQ Pharmacy Survey on Patient Safety Culture (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/pharmwebinar/sorraslides.pdf
      January 01, 2014 - Using the AHRQ Pharmacy Survey on Patient Safety Culture 9 9 Development of the AHRQ Pharmacy Survey on Patient Safety Culture Joann Sorra, PhD Project Director CAHPS and SOPS User Network Westat 10 10 What is Patient Safety Culture? “The way we do things around here” Exists at multiple leve…

4704. Section 3: Teaching the Key Concepts and Tools | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/team/teach/index.html
      August 01, 2023 - Section 3: Teaching the Key Concepts and Tools TeamSTEPPS has been taught in a 2-day format, is often taught in a half-day format, and is also frequently taught in smaller segments that are only 15-30 minutes long. In the introduction and each module, we provide advice to instructors on how to teach relevant co…

4705. Section 3: Teaching the Key Concepts and Tools | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/situation/teach/index.html
      August 01, 2023 - Section 3: Teaching the Key Concepts and Tools TeamSTEPPS 3.0 has been taught in a 2-day format, is often taught in a half-day format, and is also frequently taught in smaller segments that are only 15-30 minutes long. While in-person trainings have been the norm, virtual trainings using an online platform are …

4706. Section 3: Teaching Mutual Support Key Concepts and Tools  | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/mutual/teach/index.html
      August 01, 2023 - Section 3: Teaching Mutual Support Key Concepts and Tools  TeamSTEPPS has been taught in a two-day format, is often taught in a half-day format, and is also frequently taught in smaller segments that are only 15–30 minutes long. In the introduction and each module, we provide advice to instructors on how to tea…

4707. Measurement and Outcomes Workgroup | CDSiC
      cdsic.ahrq.gov/cdsic/cdsic-stakeholder-community-outreach-center/measurement-outcomes
      January 02, 2025 - : Skip to main content HHS.gov Menu Main navigation CDS Home CDS Innovation Collaborative An official website of the Department of Health & Human Services …

4708. Trust and Patient-Centeredness Workgroup | CDSiC
      cdsic.ahrq.gov/cdsic/cdsic-stakeholder-community-outreach-center/trust-patient-centeredness
      January 02, 2025 - : Skip to main content HHS.gov Menu Main navigation CDS Home CDS Innovation Collaborative An official website of the Department of Health & Human Services …

4709. PS Grantee | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/index.html?page=13
      January 01, 2024 - Grantee Final Reports: Patient Safety Final reports from research grants administered since 2000 on a variety of patient safety topics, such as measure development, medication safety, and diagnostic safety. The Agency for Healthcare Research and Quality Center for Quality Improvement and Patient Safety subdivis…

4710. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare July 2020 Meeting Summary (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-072320.pdf
      November 06, 2020 - Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare July 2020 Meeting Summary Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare July 2020 …

4711. Medical Devices in the "Wild" | PSNet
      psnet.ahrq.gov/web-mm/medical-devices-wild
      March 27, 2024 - Medical Devices in the "Wild" Citation Text: Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

4712. Creating an Environment of Consensus –The challenges of implementing a governance structure to run an HIE (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/2006Estrin_Trk4_051311comp.pdf
      March 08, 2006 - Creating an Environment of Consensus –The challenges of implementing a governance structure to run an HIE Creating an Environment of Consensus – The challenges of implementing a governance structure to run an HIE Funding: AHRQ Contract 290-04-0006; State of Tennessee; Vanderbilt University. This presentation…

4713. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/84413/psn-pdf
      February 23, 2022 - A Loss of Trust and a Missed Diagnosis February 23, 2022 Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counci…

4714. Learn From Defects Tool (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/learn_from_defects.docx
      December 01, 2017 - Learn From Defects Tool AHRQ Safety Program for Surgery Learn From Defects Tool – Perioperative Setting 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 statem…

4715. A Loss of Trust and a Missed Diagnosis | PSNet
      psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
      October 31, 2023 - SPOTLIGHT CASE A Loss of Trust and a Missed Diagnosis Citation Text: Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format:…

4716. Pregnant With Danger | PSNet
      psnet.ahrq.gov/web-mm/pregnant-danger
      January 12, 2011 - abdominal pain for 5 hours after eating a greasy meal. 28-year-old G2P1 at 25 weeks’ gestation slips and falls

4717. Crosscutting-Horizon-Scan-High-Impact-1412 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/crosscutting-horizon-scan-high-impact-1412.pdf
      December 01, 2014 - designed to interrupt propofol infusion if the patient’s oxygen saturation level or respiration rate falls … If the onus of improving patient adherence falls on the provider, staffing needs might increase due … The ED’s physical layout may pose a risk of falls for elderly patients, narrow and thin mattresses … informally reported positive findings initially, which indicated revisit rates decreased and fewer falls

4718. CHIPRA Quality Demonstration Grant Program Evaluation Highlight No. 5 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight05.pdf
      September 08, 2015 - member said, “Until you get your EHR up to speed with what you’re doing clinically, your EHR is falling … “Until you get your EHR up to speed with what you’re doing clinically, your EHR is falling short.

4719. Final Progress Report: Patient-centered approach to reducing harm from VTE (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/rothberg-report.pdf
      January 01, 2024 - Although this definition does not contain a time frame, we will include only falls in hemoglobin or

4720. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866622/psn-pdf
      August 28, 2024 - or huddle with direct frontline team members regarding a specific safety concern, such as patient falls