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4761. References (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-131-references.pdf
      October 23, 2013 - References References 1. Berry JG, Toomey SL, Zaslavsky AM, Jha AK, Nakamura MM, Klein DJ, Feng JY, Shulman S, Chiang VK, Kaplan W, Hall M, Schuster MA. Pediatric readmission prevalence and variability across hospitals. JAMA. 2013;309(4):372–380. 2. Pelletier AJ, Mansbach JM, …

4762. Case Example #7: Cherokee Health Systems | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-7.html
      July 01, 2019 - Case Example #7: Cherokee Health Systems This report is based on research conducted by Abt Associates in partnership with the MacColl Center for Health Care Innovation and Bailit Health Purchasing, Cambridge, MA, under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD …

4763. 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…

4764. Toolkit for Using the AHRQ Quality Indicators - A “How to” Guide for Improving Hospital Quality and Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
      December 01, 2017 - Toolkit for Using the AHRQ Quality Indicators - A “How to” Guide for Improving Hospital Quality and Safety Slide presentation of the webinar held on August 1, 2016 The Agency for Healthcare Research and Quality (AHRQ) held a Webinar on August 1, 2016, to provide an overview of the AHRQ Quality Indicators (QIs…

4765. Background for AHRQ Quality Indicators
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a2_combo_boardpresentation.pptx
      October 01, 2015 - Background for AHRQ Quality Indicators Tool A.2 Slide ‹#› Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety Tool A.2 Slide ‹#› Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety AHRQ Quality Indicators Toolkit Prepared by RAND and …

4766. Frequently Asked Questions - RFA-HS-24-004: State-based Healthcare Extension Cooperatives to Accelerate Implementation of Actionable Knowledge into Practice (U19) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/funding/fund-opps/RFA-HS-24-004-faq-112524.pdf
      November 25, 2024 - Frequently Asked Questions - RFA-HS-24-004: State-based Healthcare Extension Cooperatives to Accelerate Implementation of Actionable Knowledge into Practice (U19) RFA-HS-24-004: State-based Healthcare Extension Cooperatives to Accelerate Implementation of Actionable Knowledge into Practice (U19) Fr…

4767. A System to Describe and Reduce Medical Errors in Primary Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kaprielian_9.pdf
      January 01, 2007 - A System to Describe and Reduce Medical Errors in Primary Care A System to Describe and Reduce Medical Errors in Primary Care Victoria Kaprielian, MD; Truls Østbye, MD, PhD; Samuel Warburton, MD; Devdutta Sangvai, MD, MBA; Lloyd Michener, MD Abstract Although much attention has been focused on finding wa…

4768. The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
      March 27, 2008 - The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures 1 The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures Lawrence L. Faltz, MD, FACP; John N. Morley, MD, FACP…

4769. Final Progress Report: Factors That Enhance Diagnostic Imaging Safety in the Ambulatory Setting (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/lacson-report.pdf
      January 01, 2025 - Final Progress Report: Factors That Enhance Diagnostic Imaging Safety in the Ambulatory Setting Project Title: Factors that Enhance Diagnostic Imaging Safety in the Ambulatory Setting Principal Investigator: Ronilda Lacson, MD, PHD Team Members: Ramin Khorasani, MD, MPH Ivan Ip, MD, MPH Sonali Desai, MD Allen Ka…

4770. 6Bb-Toolkit-Fasttrack-Complete (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/ambulatory/6bb-toolkit-fasttrack-complete.pdf
      October 01, 2021 - 1 OVERVIEW The Six Building Blocks: A Team-Based Approach to Improving Opioid Management in Primary Care How-To- Implement Toolkit: Overview Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 5600 Fishers Lane Rockville, MD 20857 Contract No. HHSP23320…

4771. Pediatric Diagnostic Safety: State of the Science and Future Directions (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-pediatric-safety.pdf
      September 01, 2023 - diagnosis-focused clinical and health services research in the portfolios of pediatric research collaborative groups

4772. Toolkit for Reducing CAUTI in Hospital Units: Implementation Guide (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/implementation-guide_0.pdf
      September 01, 2015 - Evaluate practice patterns for certain physician groups, specialties, or units.

4773. Toolkit for Reducing CAUTI in Hospital Units: Implementation Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide.pdf
      September 01, 2015 - Evaluate practice patterns for certain physician groups, specialties, or units.

4774. Final Progress Report: Investigating Failures of Notification and Monitoring in Outpatient Care: the Safety Promotion Action Research and Knowledge Network (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/sarkar2-report.pdf
      January 01, 2024 - English-speaking patients and focused on California and may not be generalizable to other language groups

4775. 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 - programs provide, at no cost to families: – Family education and counseling, home visits, parent support groups

4776. Regulation of Health Policy: Patient Safety and the States (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weinberg.pdf
      March 01, 2004 - can also be considered errors of commission; for example, when brought about by the exclusion of groups

4777. Overview of Patient Safety Learning Laboratory (PSLL) Projects | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/resources/learning-lab/index.html
      August 01, 2025 - Overview of Patient Safety Learning Laboratory (PSLL) Projects Introduction Patient safety learning laboratories (PSLLs) take a systems engineering approach to allow researchers and healthcare providers to evaluate clinical processes and enhance work and information flow to improve patient safety. The learning …

4778. Chartbook on Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
      January 01, 2020 - Falls were divided into two groups: Falls known to have been Assisted, and Falls considered Unassisted … Falls were divided into two groups: Falls known to have been Assisted, and Falls considered Unassisted

4779. Appendix III (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apiiig.html
      June 01, 2010 - Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services Appendix III (continued) Previous Page Next Page Table of Contents Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services Executive Summary Introduction and Scan Methodology …

4780. Appendix G. References for Fault Tree Model Probability Estimates | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/stpra/stpraapg.html
      October 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers Appendix G. References for Fault Tree Model Probability Estimates Previous Page Next Page Table of Contents Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers Executive Summary Chap…