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  1. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Jack_28.pdf
    February 21, 2008 - of low health literacy; lack of coordination in the “hand-off” from the hospital to community care, gaps
  2. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Dingley_14.pdf
    February 06, 2008 - care at various times throughout the day, often dispersed over several locations, creating spatial gaps
  3. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/stpra/stpra.pdf
    March 01, 2012 - When we found gaps in these estimates, we performed additional and more focused literature reviews or
  4. www.ahrq.gov/sites/default/files/2024-12/lin-report.pdf
    January 01, 2024 - Final Progress Report: Measurement of Decision Quality in Coronary Artery Disease Measurement of Decision Quality in Coronary Artery Disease Grace A. Lin, MD, MAS, Principal Investigator R. Adams Dudley, MD, MBA, Mentor Rita F. Redberg, MD, MSc, Co-mentor Organization: University of California, San Francisco …
  5. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/043-vap-prevention-notes.docx
    October 01, 2024 - AHRQ Safety Program for MRSA Prevention Prevention of Ventilator-Associated Pneumonia & Non-Ventilator Healthcare-Associated Pneumonia ICU & Non-ICU Slide Title and Commentary Slide Number and Slide Prevention of Ventilator-Associated Pneumonia & Non-Ventilator Healthcare-Associated Pneumonia SAY: Welcome to this …
  6. www.ahrq.gov/sites/default/files/2024-07/buckley-report.pdf
    January 01, 2024 - Final Progress Report: Midcoast Maine Patient Safety and IT Integration Title: Midcoast Maine Patient Safety and IT Integration Principal Investigator: Maureen Buckle y, PhD, RN – Vice President of Patient Care Team Members: Northeast Health and Partner Organizations Donna Deblois, MS, RN – Executive Dire…
  7. www.ahrq.gov/sites/default/files/2024-01/weingart-report.pdf
    January 01, 2024 - Final Progress Report: Oral Chemotherapy Safety in Ambulatory Oncology: A Proactive Risk Assessment Final Progress Report 1.0 TITLE PAGE Oral Chemotherapy Safety in Ambulatory Oncology: A Proactive Risk Assessment Principal Investigator Saul N. Weingart, MD, PhD Co-Investigators Maureen Connor, RN, MPH Syl…
  8. www.ahrq.gov/sites/default/files/2024-10/feudtner-report.pdf
    January 01, 2024 - Final Progress Report: Profiling the Needs of Dying Children FINAL PROGRESS REPORT Title of Project: Profiling the Needs of Dying Children Principal Investigator: Chris Feudtner, MD, PhD, MPH Organizations: The University of Washington (2000-2002) and The Children's Hospital of Philadelphia (2002-2006) Date…
  9. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_audit_briefing.pptx
    December 01, 2017 - Presentation: Auditing Your Briefings and Debriefings Auditing Your Briefings and Debriefings Process AHRQ Safety Program for Surgery Implementation AHRQ Pub. No. 16(18)-0004-15-EF December 2017 AHRQ Safety Program for Surgery – Implementation SAY: Let’s continue our discussion around briefings and debriefings. T…
  10. www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/3-are-you-ready/cahps-ambulatory-care-guide-section-3.pdf
    May 01, 2017 - The CAHPS Ambulatory Care Improvement Guide: Are You Ready To Improve? The CAHPS Ambulatory Care Improvement Guide Practical Strategies for Improving Patient Experience Section 3: Are You Ready To Improve? Visit the AHRQ Website for the full Guide. May 2017 (updated) https://www.ahrq.gov/cahps/quality-improve…
  11. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Quinn.pdf
    January 01, 2004 - Can an Academic Health Care System Overcome Barriers to Clinical Guideline Implementation? 291 Can an Academic Health Care System Overcome Barriers to Clinical Guideline Implementation? Debra Quinn, Mary Cooper, Lynn Chevalier, Jerry Balentine, Lawrence Kadish, Steven Walerstein, Fredric Weinbaum, Mark Ca…
  12. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Stalhandske2_70.pdf
    March 01, 2006 - VHA’s National Falls Collaborative and Prevention Programs VHA’s National Falls Collaborative and Prevention Programs Erik Stalhandske, MPP, MHSA; Peter Mills, PhD; Pat Quigley, PhD, ARNP, CRRN, FAAN; Julia Neily, MS, MPH; James P. Bagian, MD, PE Abstract Falls are a high-volume, high-cost problem in he…
  13. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Hagg_80.pdf
    January 01, 2007 - Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption Heather Woodward Hagg, MS; Jamie Workman-Germann, MS; Mindy Flanagan, PhD; Deanna Suskovich, BA; Susan Schachitti, MBA; Christine Corum, MS; Bradley N. Do…
  14. www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/ps-research-summary-pfe.pdf
    April 30, 2025 - ■ Another project filled medical literature gaps regarding how SDM relates to health disparities … development activities resulted in contributions to the medical literature that fills some of the gaps
  15. www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie.pdf
    June 01, 2023 - With Outpatient Decision Support 2000- 2003 $1,614,021 Purpose: (1) Improve understanding of the gaps
  16. www.ahrq.gov/sites/default/files/2024-02/kane-gill-report.pdf
    January 01, 2024 - Our project addressed current medication safety gaps by first prospectively identifying NH residents
  17. www.ahrq.gov/sites/default/files/2024-11/wakefield2-report.pdf
    January 01, 2024 - this study was designed to make a significant contribution to understanding VOs by addressing several gaps
  18. www.ahrq.gov/sites/default/files/2024-01/minnitti-report.pdf
    January 01, 2024 - During the analysis of the FMEA ratings, variability and gaps in ratings suggested a problem with the
  19. www.ahrq.gov/sites/default/files/2024-07/jerant-report.pdf
    January 01, 2024 - The research summarized in this final report begins to fill these important research gaps.
  20. www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-26-ehr-and-mu.pdf
    September 01, 2015 - Flow sheets can be used to organize patient information, identify gaps in patient care, and suggest

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