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4561. Communication Failure—Who's in Charge? | PSNet
      psnet.ahrq.gov/web-mm/communication-failure-whos-charge
      April 01, 2018 - throughout the night, neither of them recognized a need to go to the hospital to evaluate the child. … When, as in this case, data falls outside what the mental model predicts or therapy does not produce … Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective … Trends in hospital volume and operative mortality for high-risk surgery. … Retrospective review of emergency response activations during a 13-year period at a tertiary care children's hospital

4562. Background -- AHRQ and other funders interest in promoting faster movement from research to practice/science to service/TRIP/T (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Carpenter.pdf
      January 01, 2004 - Unfortunately, putting these results into practice often falls short of their envisioned potential. … prompt a hospital administrator to seek a patient safety culture-assessment instrument. … “What’s in it for me?” … In: Advances in patient safety: from research to implementation. … Stages in the implementation of innovative clinical programs in complex organizations.

4563. Background -- AHRQ and other funders interest in promoting faster movement from research to practice/science to service/TRIP/T (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Carpenter.doc
      January 01, 2004 - Unfortunately, putting these results into practice often falls short of their envisioned potential. … prompt a hospital administrator to seek a patient safety culture-assessment instrument. … “What’s in it for me?” … In: Advances in patient safety: from research to implementation. … Stages in the implementation of innovative clinical programs in complex organizations.

4564. Enhancing Complex Care through an Integrated Care Coordination Information System - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017832-dorr-final-report-2012.pdf
      January 01, 2012 - Five of the practices have a hospital within their community, and all of the physicians in the six study … These sites ranged from rural clinics to large hospitals. … Difference in difference at 6 months of ED visits and hospital bed days Group Care Coordination Quality … Hospital bed-days did decline in the first 6 months in the care coordination group over the quality … Changes in utilization and efficiency by incentive arm are preliminary but mixed; hospital bed-days

4565. Spotlight on Colorado | Agency for Healthcare Research and Quality
      www.ahrq.gov/policymakers/chipra/statesummaries/co-spotlight.html
      July 01, 2015 - Each SBHC received $10,000 to $13,000 in grant funds for each year it participated in the demonstration … Increase in the percentage of adolescents seen in participating Colorado SBHCs with all EPSDT- recommended … year in the demonstration (2011, 2012, or 2013 depending on the cohort) and in 2014. … Implemented the questionnaire in 10 SBHCs in Colorado. 2 Two-thirds of the middle school students (66 … of community resources for families, and establishing a memorandum of understanding with the local hospital

4566. EvidenceNow Executive Summary - Virginia Cooperative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/cooperatives/evidencenow-executive-summary-va.pdf
      November 01, 2017 - - Virginia Cooperative Virginia Cooperative Virginia EvidenceNOW: Advancing Heart Health in … how quality improvement support can accelerate the dissemination and implementation of new evidence in … age-adjusted death rates due to heart disease can be found in less populous rural areas, including … Ninety of these are clinician-owned practices (i.e., independent); 126 are hospital-affiliated. … Practices seem more willing to spend time on measures that are in some way tied to incentives.

4567. Multidimensional Health Assessment Questionnaire (MDHAQ) (pdf file)
      integrationacademy.ahrq.gov/sites/default/files/2020-07/MDHAQ.pdf
      January 01, 2020 - Get in and out of a car, bus, train, or airplane? 0 1 2 3 i. … Participate in recreational activities and sports as you would like, if you wish? … the ears Stuffy nose Sores in the mouth Dry mouth Problems with smell or taste Lump in your throat … When you awakened in the morning OVER THE LAST WEEK, did you feel stiff? … hospital �No �Yes A fall, broken bone, or other accident or trauma �No �Yes An important new symptom

4568. CAHPS Clinician & Group Adult Survey 3.1 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/adult-english-cg-3-1-2351a.pdf
      December 01, 2020 - named in Question 1 as “this provider.” … that person in the last 6 months. 2. … Do not include care you got when you stayed overnight in a hospital. … In the last 6 months, how often did this provider explain things in a way that was easy to understand … In general, how would you rate your overall health?

4569. Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic | PSNet
      psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
      January 12, 2022 - which health services are delivered across care settings, in particular in hospital emergency departments … particular, hospital data has indicated an increased risk of hospital-acquired infections during the … Patient safety concerns in COVID-19-related events: a study of 343 event reports from 71 hospitals in … We also have critical access hospitals, specialty hospitals, and hospital-owned skilled nursing facilities … Our hospitals have great protocols in place for pressure injury prevention, but prone positioning brought

4570. Final Progress Report: Shared Decision Making in Surgery To Improve Patient Safety and Reduce Liability (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/domino-report.pdf
      January 01, 2024 - hospital patients. … Risk management files that did not involve patient care (e.g., visitor falls) were not included … hospital, additional outpatient treatment, unplanned admission or readmission, or emergency room visit … All complaints and errors resulted in some treatment or increased level of care, either within the hospital … Hospital informed consent for procedure forms: Facilitating quality patient-physician interaction.

4571. 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 - a pharmacy-based review of medication orders in two pediatric hospitals, Folli et al.9 found that errors … Medication error prevention by clinical pharmacists in two children’s hospitals. … community teaching hospital. … Risk factors for unlicensed and off-label drug use in children outside the hospital. … Risk factors for unlicensed and off-label drug use in children outside the hospital.

4572. Timely Temperatures Upon Arrival in Level 2 or Higher Nurseries for Low Birthweight Neonates (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-117-fullreport.pdf
      October 18, 2017 - We have collected data from chart review at three diverse hospitals in New York City. … provides increasing risk the further it falls below 37° C. … National improvement is needed in the methods used to assign race and ethnicity to newborns in the hospital … Provider Level Hospital: Can compare hospitals Intended use: Is measure intended to support meaningful … Our chart review data from three diverse hospitals in New York City showed variation in temperatures

4573. Are We Pushing Graduate Nurses Too Fast? | PSNet
      psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
      November 16, 2022 - this SICU since graduation; she had completed the hospital-based CRRT training in the prior month. … In this hospital, RNs who regularly cared for SICU patients administered CRRT along with other care needed … RNs received special training in this technique from expert nurses in this hospital and received a certificate … CRRT is a high-risk procedure that is handled differently by different hospitals. … June 29, 2022 Families as partners in hospital error and adverse event surveillance.

4574. Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/confidreportguide_1.pdf
      March 01, 2016 - practices and acute care hospitals. … individual physicians who work only in one unit of the hospital (Brehaut, et al., 2016). 16 … Other benchmarks, such as the 90th percentile for all safety net hospitals in a given region, need … Data feedback efforts in quality improvement: lessons learned from US hospitals. … Case example of Massachusetts General Hospital Massachusetts General Hospital (MGH) developed a framework

4575. Rural Iowa Redesign of Care Delivery with EHR Functions | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/rural-iowa-redesign-care-delivery-ehr-functions
      January 01, 2023 - Report ( PDF , 144.65 KB) Disclaimer Disclaimer The findings and conclusions in … No statement in this report should be construed as an official position of AHRQ or of the U.S. … Electronic Health Record/Electronic Medical Record Care Setting Ambulatory Setting Hospital … rural health care hospital inpatient units, ambulatory care, and two primary care clinics. … After thirty months the hospital and clinics had sustained a 70 percent CPOE rate with over 250 evidence-based

4576. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73953/psn-pdf
      October 27, 2021 - Some common risk factors, described in a 2019 article in American Family Physician,1 are listed in Table … Utilizing EHR-enabled CDSSs has been shown to be effective in reducing the prescribing of PIMs in hospital … benefits of deprescribing include reduced morbidity and mortality, improved quality of life, decreased hospital … admissions, reduced falls, and improved mental status. … The pharmacist’s role in successful deprescribing through hospital medication reconciliation.

4577. Daily Care Processes Guide for Reducing Ventilator-Associated Events in Mechanically Ventilated Patients (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/daily-care-processes-guide.pdf
      January 01, 2017 - would be easier to add a nightlight to bathrooms before redesigning floor plans to reduce patient falls … and housed in your unit at some time during their hospital stay per month (patients are counted in … Estimating health care-associated infections and deaths in U.S. hospitals, 2002. … Strategies to prevent ventilator-associated pneumonia in acute care hospitals. … Implementing a ventilator bundle in a community hospital.

4578. Speech Telerehabilition after stroke: Proof of Concept and Feasibility - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r03hs025043-ellis-final-report-2019.pdf
      January 01, 2019 - Scope: 30 stroke survivors with aphasia living in community settings participated in the study. … Settings: The study was completed in community-based setting. … Participants: Participants were recruited locally from local inpatient and outpatient clinics at a local hospital … As education level and age increase, change in WAB score falls. … Seminars in Speech and Language, 2019, 40(5): 359-369. DOI: 10.1055/s-0039-1688695.

4579. Chapter 3. Outline the Evidence and Identify Best Practices | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide3.html
      February 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism Chapter 3. … hospitals. … Admitted to Hospital. … who require prophylaxis extended beyond the hospital stay. … the context of making decisions about prophylaxis for patients leaving the hospital.

4580. Chapter 3. Outline the Evidence and Identify Best Practices | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide3.html
      February 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism Chapter 3. … hospitals. … Admitted to Hospital. … who require prophylaxis extended beyond the hospital stay. … the context of making decisions about prophylaxis for patients leaving the hospital.