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  1. www.ahrq.gov/sites/default/files/2024-02/gurwitz2-report.pdf
    January 01, 2024 - Final Progress Report: Improving Safety After Hospitalization in Older Persons on High-Risk Medications Title of Project: Improving Safety After Hospitalization in Older Persons on High-Risk Medications Principal Investigator: Jerry H. Gurwitz, MD Principal Team Members: Kathleen M. Mazor, EdD; Terry S. Field, DSc;…
  2. www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/chipra-primary-care-physician-reporting.pdf
    December 01, 2016 - Doing QI and moving measures doesn’t happen overnight, especially trying to introduce population management
  3. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
    April 02, 2008 - a critical event, suggesting that any team consisting of the same individuals is very unlikely to happen
  4. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
    January 01, 2004 - We have since come to realize that preventable medical deaths and adverse events happen in Wisconsin
  5. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
    January 01, 2003 - Did any significant unplanned events happen during your shift?
  6. www.ahrq.gov/sites/default/files/wysiwyg/topics/pridx-framework.pdf
    July 05, 2023 - As one SME expressed, payer involvement in diagnostic safety “needs to happen,” a sentiment that was
  7. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressureulcertoolkit/putoolssect7.pdf
    January 01, 2004 - What will happen? … describe key processes in your organization where pressure ulcer prevention activities could or should happen
  8. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
    April 04, 2008 - A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care Ranjit Singh, MA, MB, BChir (Cantab.), MBA; Wilson Pace, MD; Ashok Singh, MA, MB, BChir (Cantab); Chester Fox, MD; Gurdev Singh, MSc…
  9. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/1_preventablehospitaledvisits-overview-ig.pdf
    June 02, 2025 - Overview Slide AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Facilitator Training: Overview of On-Time This version of the On-Time Facilitator Training Overview is for training Facilitators who have not had pressure ulcer prevention training. If they h…
  10. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/factraining.html
    December 01, 2014 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Facilitator Training Slide 1: Overview of On-Time Slide 2: On-Time Pressure Ulcer Prevention Facilitator Training Say: Welcome to the On-Time Pressure Ulcer Prevention Facilitator Training.  This 2-day Facilitator training …
  11. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/001-clabsi-prevention-webinar-slides.pptx
    October 01, 2024 - AHRQ Safety Program for MRSA Prevention AHRQ Safety Program for MRSA Prevention Prevention of Central Line-Associated Bloodstream Infections ICU & Non-ICU AHRQ Pub. No. 25-0007 October 2024 AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU Prevention of CLABSI 1 Educational Objectives Define a central line-…
  12. www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apiiii.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 …
  13. www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight09.pdf
    September 08, 2015 - How are CHIPRA quality demonstration States supporting the use of care coordinators? Evaluation Highlight No. 9 The CHIPRA Quality Demonstration Grant Program In February 2010, the Centers for Medicare & Medicaid Services (CMS) awarded 10 grants, funding 18 States, to improve the quality of health care for chil…
  14. www.ahrq.gov/sites/default/files/2024-02/cohen2-report.pdf
    January 01, 2024 - An “and” gate is used to link events that must all happen (A and B) to produce the studied adverse outcome … An “or” gate is used to link events for which only one of the events must happen (A or B) to produce
  15. www.ahrq.gov/sites/default/files/2024-02/berry-report.pdf
    January 01, 2024 - Contamination in ascertaining outcomes may happen when patients are transferred within the hospital
  16. www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-146-section-2.pdf
    September 01, 2011 - ADAPT to Adult-Focused Health Care ADolescent Assessment of Preparation for Transition (ADAPT) to Adult-Focused Health Care Detailed Measure Specifications Center of Excellence for Pediatric Quality …
  17. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-cancer-care-transcript.pdf
    June 01, 2017 - Introducing the CAHPS Cancer Care Survey" Transcript Introducing the CAHPS® Cancer Care Survey June 2017  Webcast Speakers Caren Ginsberg, PhD, Director, CAHPS Division, Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality Ashley Wilder Smith, PhD, MPH, Chief of t…
  18. www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-facilitators-guide.pdf
    February 04, 2022 - These examples can be from actual experience or situations that you imagine could happen. 3. … � How could that happen in your setting? … These examples can be from actual experience or situations that you imagine could happen.
  19. www.ahrq.gov/sites/default/files/2024-01/joseph1-report.pdf
    January 01, 2024 - Instead, the design activities should happen iteratively in small cycles.
  20. www.ahrq.gov/sites/default/files/2024-11/kupka-report.pdf
    January 01, 2024 - This may happen once or at different, even multiple, points in time during the course of the preoperative

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