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1721. Work System Analysis: The Key to Understanding Health Care Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
      April 22, 2004 - Work System Analysis: The Key to Understanding Health Care Systems 337 Work System Analysis: The Key to Understanding Health Care Systems Ben-Tzion Karsh, Samuel J. Alper Abstract Many articles in the medical literature state that medical errors are the result of systems problems, require systems analyses, a…

1722. Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Wideman.pdf
      April 20, 2004 - Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation 437 Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation Mary V. Wideman, Michael E. Whittler, Timothy M. Anderson Abstract An electronic barcode medication administration sy…

1723. 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 …

1724. Pillars of a Smart, Safe Operating Room (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Seagull_98.pdf
      April 07, 2008 - Pillars of a Smart, Safe Operating Room Pillars of a Smart, Safe Operating Room F. Jacob Seagull, MD; Gerald R. Moses, PhD; Adrian E. Park, MD Abstract Major gains in patient safety can be achieved through development of innovative approaches to the care of surgical patients. Investigators and clinicians have…

1725. CAHPS 2024 Research Meeting Summary (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/2024-virtual-research-meeting-summary-prems-proms.pdf
      January 01, 2024 - CAHPS 2024 Research Meeting Summary Consumer Assessment of Healthcare Providers and Systems (CAHPS®) 2024 Research Meeting Summary Patient-Reported Experience and Outcome Measures (PREMs and PROMs) in Research and Clinical Practice November 2024 2 Table of Contents Introduction ......................…

1726. Preventing-Cauti-Engaging-Clinicians-Transcript (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-engaging-clinicians-transcript.doc
      May 14, 2013 - And given this gap between what should be done and what is done, there has been recent emergence of a

1727. Preventing CAUTI: Engaging Clinicians and Senior Leadership to Implement Change (May 14, 2013) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/preventing-cauti-engaging-clinicians-transcript.html
      December 01, 2017 - And given this gap between what should be done and what is done, there has been recent emergence of a

1728. Two More “Es” and How To Spread (Transcript) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/how-to-spread.html
      April 01, 2013 - And there’s evidence out there, and you know there is a gap between your own practice and what evidence

1729. Final Progress Report: The PeaceHealth Community-wide Electronic Shared Medication List (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/stock-easton-report.pdf
      January 01, 2024 - It is believed that access to accurate information is a serious gap that prevents providers from delivering

1730. AHRQ Comparative Health System Performance Initiative: Program Overview and Accomplishments, 2015-2020 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/chsp/CHSP-accomplishments-report-2021.pdf
      January 01, 2021 - AHRQ Comparative Health System Performance Initiative: Program Overview and Accomplishments, 2015-2020 AHRQ Comparative Health System Performance Initiative: Program Overview and Accomplishments, 2015-2020 US DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality 5600 Fishers Lane …

1731. Weight Summary (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/functional-specifications.docx
      February 10, 2014 - If the facility is not using the On-Time Wound Assessment, the EMR vendor conducts a gap analysis to

1732. Final Progress Report: The National Quality Forum Annual Meeting 2005 (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/nishimi2-report.pdf
      January 01, 2025 - Brock noted that the Research and Quality Improvement Council believes that the gap of greatest concern

1733. Myth Busting: Using the CG-CAHPS 12-Month Survey for Quality Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20131008_cg/mythbustingwebcast.pdf
      October 01, 2013 - Like our colleagues at Dean, we see a gap between the “courtesy” and “helpfulness” scores as well.

1734. AHRQ Issue Brief: Understanding the AI Wave: Foundational Knowledge for Improving Diagnosis and Beyond (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-brief-ai-wave.pdf
      June 01, 2025 - This Issue Brief seeks to alleviate the AI-knowledge gap by elucidating what AI is, how it works, its

1735. Functional Specifications for Pressure Ulcer Healing | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/functional-specs.html
      December 01, 2017 - If the facility is not using the On-Time Wound Assessment, the EMR vendor conducts a gap analysis to

1736. Final progress Report: Improving Over-the-Counter Medication Safety for Older Adults (pdf file)
      www.ahrq.gov/sites/default/files/2024-03/chui-report.pdf
      January 01, 2024 - fact that OTC medication misuse is prevalent and costly, this potentially enormous patient safety gap

1737. Transitioning Newborns from NICU to Home: Family Information Packet, Appendix B (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb.pdf
      June 02, 2025 - ■ Distal tubule function: Urine anion gap of infants with nephrocalcinosis is high, and serum bicarbonate

1738. Resource List - AHRQ Nursing Home Survey (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursinghome-resourcelist.pdf
      April 01, 2023 - account setup and login) Leading a Culture of Safety: A Blueprint for Success was developed to bridge a gap

1739. Final Progress Report: Consumer-Led Workshop To Advance Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/peck-report.pdf
      January 01, 2024 - Final Progress Report: Consumer-Led Workshop To Advance Patient Safety Report to the Agency for Healthcare Research & Quality from the Consumer-Led Workshop to Advance Patient Safety1 (October 16-18, 2003, Houston, TX) Prepared on Behalf of Workshop Participants by Jonathan Peck, Institute for Alternative Futu…

1740. Diagnostic Issue Brief 19 Electronic Test Result Communication in the Era of the 21st Century Cures Act (pdf file)
      www.ahrq.gov/sites/default/files/publications2/files/diagnostic-safety-issue-brief-test-result-communication.pdf
      July 01, 2024 - Diagnostic Issue Brief 19 Electronic Test Result Communication in the Era of the 21st Century Cures Act PATIENT SAFETY e Issue Brief 19 Electronic Test Result Communication in the Era of the 21st Century Cures Act This page intentionally left blank. e Issue Brief 19 Electronic Test Result Communication …