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4081. Final Progress Report: VTE Safety Toolkit: A Systems Approach to Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/zierler-report.pdf
      January 01, 2024 - Final Progress Report: VTE Safety Toolkit: A Systems Approach to Patient Safety Title: VTE Safety Toolkit: A Systems Approach to Patient Safety Principal Investigator: Brenda K. Zierler, PhD1 Team Members: Ann Wittkowsky, PharmD2 Robb Glenny, MD3 Seth Wolpin, PhD1 Jung-Ah Lee, MN1 Gene Peterson, MD, PhD3 Fre…

4082. Final Progress Report: Evaluating e-Prescribing in a Community-Based, Integrated Health System (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/devine-report.pdf
      January 01, 2024 - Final Progress Report: Evaluating e-Prescribing in a Community-Based, Integrated Health System K-08 Final Progress Report Evaluating e-Prescribing in a Community-Based, Integrated Health System Principal Investigator Emily Beth Devine, PharmD, MBA, PhD, BCPS, FASHP Primary Mentors Sean D. Sullivan, PhD, David K…

4083. Final Progress Report: Shared Online Health Records for Patient Safety and Care (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/middleton-wald-report.pdf
      January 01, 2024 - Final Progress Report: Shared Online Health Records for Patient Safety and Care FINAL REPORT: December, 18th 2007 Shared Online Health Records for Patient Safety and Care Principal Investigator: Blackford Middleton, MD, MPH, MSc; bmiddleton1@partners.org Brigham and Women’s Hospital Blackford Middleton, MD, MPH,…

4084. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
      www.ahrq.gov/sites/default/files/publications2/files/distributed-cognition-er-nurses_0.pdf
      August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Issue Brief 8 Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department PATIENT SAFETY e This page intentionally left blank. e Issue Brief 8 Distributed Cognition and the Rol…

4085. Mutual Support: Severe Hypertension (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support-speaker-notes.pdf
      July 01, 2023 - Mutual Support: Severe Hypertension Hospital AIM Team Leads SPPC‐II Mutual Support Severe Hypertension Module 5 of 8 SPPC‐II Toolkit SCRIPT Welcome to Module 5 of the SPPC‐II Teamwork Toolkit. In this module, we will discuss the different facets of mutual support and strategies for supporting each. 1 …

4086. Mutual Support: Severe Hypertension - PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support.pptx
      July 01, 2023 - Mutual Support: Severe Hypertension - PowerPoint Presentation Mutual Support Severe Hypertension Module 5 of 8 SPPC-II Toolkit AHRQ Pub. No. 23-0046 July 2023 Hospital AIM Team Leads SPPC-II SCRIPT Welcome to Module 5 of the SPPC-II Teamwork Toolkit. In this module, we will discuss the different facets of mutual …

4087. The National Action Alliance to Advance Patient Safety Summer Webinar Series: CDC Presentation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/addressing-workforce-safety-062723.pdf
      July 25, 2023 - The National Action Alliance to Advance Patient Safety Summer Webinar Series: CDC Presentation The National Action Alliance to Advance Patient Safety Summer Webinar Series Addressing Violence in the Workplace June 27, 2023 2:00-3:00 PM ET Special Guest Speakers 2 Martin Hatlie, JD President & CEO, Project P…

4088. Snac-Final-Report-Mar2023 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/snac-final-report-mar2023.pdf
      January 01, 2025 - Subcommittee of the National Advisory Council: Informing the National Action Alliance to Advance Patient and Workforce Safety Final Report: December 19, 2023 Submitted by: Lucy A. Savitz, Ph.D., MBA on behalf of the AHRQ Subcommittee Subcommittee of the AHRQ National Advisory Cou…

4089. Planning and Implementing the Patient Advocacy Reporting System in the Sanford Health System | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/liability/pichert.html
      August 01, 2017 - Advances in Patient Safety and Medical Liability Planning and Implementing the Patient Advocacy Reporting System in the Sanford Health System Previous Page Next Page Table of Contents Advances in Patient Safety and Medical Liability Preface Acknowledgments Prologue Silence A Commentary Ref…

4090. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
      August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Issue Brief 8 Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department PATIENT SAFETY e This page intentionally left blank. e Issue Brief 8 Distributed Cognition and the Rol…

4091. A Study of Adverse Occurrences and Major Functional Impairment Following Surgery (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Rojas.pdf
      March 15, 2004 - A Study of Adverse Occurrences and Major Functional Impairment Following Surgery 275 A Study of Adverse Occurrences and Major Functional Impairment Following Surgery Mary Rojas, Alan Silver, Christine Llewellyn, Lenora Rances Abstract Objective: The authors sought to ascertain whether adverse occurrences (AOs…

4092. 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…

4093. From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Kravitz.pdf
      February 09, 2005 - From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator 395 From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator Richard L. Kravitz, Jonathan D. Neufeld, Michael A. Hogarth, Debora A. Paterniti, William Dager, …

4094. Patient Safety Research in Medical Group Practices: Measurement and Data Challenges (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Wilson.pdf
      December 01, 2004 - Patient Safety Research in Medical Group Practices: Measurement and Data Challenges 51 Patient Safety Research in Medical Group Practices: Measurement and Data Challenges Amy R. Wilson, Bryan E. Dowd, John E. Kralewski Abstract This paper attempts to identify and discuss some of the major challenges to co…

4095. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
      January 01, 2004 - “Near-miss” Reporting System Development and Implications for Human Subjects Protection 181 “Near-miss” Reporting System Development and Implications for Human Subjects Protection Harvey J. Murff, Daniel W. Byrne, Paul A. Harris, Daniel J. France, Christa Hedstrom, Robert S. Dittus Abstract Background: R…

4096. Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Woods_78.pdf
      July 23, 2008 - Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions Donna M. Woods, EdM, PhD; Jane L. Holl, MD, MPH; Denise Angst, PhD, RN; Susan C. Echiverri, MD; Daniel Johnson, MD; David F. Soglin, MD; Gop…

4097. Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Zierler_81.pdf
      September 01, 2008 - Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety Brenda K. Zierler, PhD; Ann Wittkowsky, PharmD; Gene Peterson, MD, PhD; Jung-Ah Lee, MN; Courtney Jacobson, BA; Robb Glenny, MD; Fred Wolf, PhD; Lynne Robin…

4098. Implementing an Ambulatory e-Prescribing System: Strategies Employed and Lessons Learned to Minimize Unintended Consequences (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Devine_83.pdf
      April 06, 2008 - Implementing an Ambulatory e-Prescribing System: Strategies Employed and Lessons Learned to Minimize Unintended Consequences Implementing an Ambulatory e-Prescribing System: Strategies Employed and Lessons Learned to Minimize Unintended Consequences Emily B. Devine, PharmD, MBA; Jennifer L. Wilson-Norton, RPh, MBA…

4099. Universal ICU Decolonization: An Enhanced Protocol (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/universalicu.pdf
      September 01, 2013 - Universal ICU Decolonization: An Enhanced Protocol Universal ICU Decolonization Toolkit: An Enhanced Protocol HAIs Healthcare- Associated Infections Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov PREVENT Universal ICU Decolonization: An Enhanced Protocol …

4100. Best Practices in Medication Safety: Areas for Improvement in the Primary Care Physician’s Office (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Galt.pdf
      April 23, 2004 - Best Practices in Medication Safety: Areas for Improvement in the Primary Care Physician’s Office 101 Best Practices in Medication Safety: Areas for Improvement in the Primary Care Physician’s Office Kimberly A. Galt, Ann M. Rule, Bartholomew E. Clark, James D. Bramble, Wendy Taylor, Kevin G. Moores Abst…