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2181. Presentation: Engaging Senior Executives
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_sr-execs.pptx
      December 01, 2017 - Presentation: Engaging Senior Executives Engaging Senior Executives AHRQ Safety Program for Surgery Onboarding AHRQ Pub No. 16(18)-0004-15-EF December 2017 SAY: In this module we will discuss the importance of senior engagement on your safety program team. 1 Why Do We Need an Executive? We discussed our PSSA data …

2182. Consolidated Imaging: Implementing a Regional Health Information Exchange System for Radiology in Southern Maine (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Loux_36.pdf
      March 15, 2008 - Consolidated Imaging: Implementing a Regional Health Information Exchange System for Radiology in Southern Maine Consolidated Imaging: Implementing a Regional Health Information Exchange System for Radiology in Southern Maine Stephenie Loux, MS; Robert Coleman, BS; Matthew Ralston, MD; Andrew Coburn, PhD Abs…

2183. Patient Monitors in Critical Care: Lessons for Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_16.pdf
      January 01, 2003 - Patient Monitors in Critical Care: Lessons for Improvement Patient Monitors in Critical Care: Lessons for Improvement Frank A. Drews, PhD Abstract Unexpected incidents are common in intensive care medicine. One means of detecting, diagnosing, and treating these events is use of physiologic displays that sho…

2184. Final Progress Report: Disseminating a Web-Enabled Safety Risk Assessment (SRA) Toolkit for Designing Safer Healthcare Facilities (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/taylor-report.pdf
      January 01, 2025 - Final Progress Report: Disseminating a Web-Enabled Safety Risk Assessment (SRA) Toolkit for Designing Safer Healthcare Facilities Final Report 1. Title Page Principal Investigator: Ellen Taylor Project Title: Disseminating a web-enabled Safety Risk Assessment (SRA) toolkit for designing safer healthcare facilitie…

2185. Final Progress Report: Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization (pdf file)
      www.ahrq.gov/sites/default/files/2025-04/marin-report.pdf
      January 01, 2025 - Several hours into her stay, the CT is read as negative.

2186. Final Progress Report: Building Consensus Among States on Patient Safety Reporting (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/golden-west-report.pdf
      January 01, 2024 - The payoff is that flying is statistically quite safe, with only one accident per one billion flight hours

2187. Final Progress Report: Quality Care and Error Reduction in Rural Hospitals (pdf file)
      www.ahrq.gov/sites/default/files/2024-12/cook-hoas-report.pdf
      January 01, 2024 - In some cases, the pharmacist was on-site only a very limited number of hours per week.

2188. Final Progress Report: Improving Warfarin Management in Competitive Healthcare (pdf file)
      www.ahrq.gov/sites/default/files/2024-04/levett-report.pdf
      January 01, 2024 - Missed/Overdue Labs 6504CATC 02/23/07 1 Changing from Coumadin to Warfarin 6505CATC 12/16/05 0 After Hours

2189. 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 - surgical procedures and 100 surgical inpatients who had a major surgery (operating time greater than 3 hours

2190. Final Progress Report: Proactive Risk Assessment in the ED: Building the Safety Case (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/wears-perry-report.pdf
      January 01, 2025 - High-tempo conditions were estimated to occur about four times per year, typically lasting up to 8 hours

2191. Transitional Care Medication Safety: Stakeholders' Perspectives | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/liability/corbett.html
      August 01, 2017 - Focus groups lasted 1½ - 2 hours and were held at public locations convenient to the participants, such

2192. Role of the External Coach in Advancing Research Translation in Hospital-Based Performance Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Donaldson_87.pdf
      April 23, 2008 - sites, the project team developed a role description for a project coach that clarified availability (hours

2193. The Impact of Standardized Order Sets on Quality and Financial Outcomes (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Ballard_12.pdf
      February 02, 2008 - PN-5b initial antibiotic received within 4 hours of hospital arrival. 6.

2194. Final Progress Report: NYU Patient Imaging, Quality and Safety Laboratory (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/horwitz-report.pdf
      January 01, 2025 - conducted dozens of qualitative interviews, reviewed hundreds of adverse event reports, spent over 100 hours

2195. Network of Patient Safety Databases Chartbook, 2021 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2021.pdf
      January 01, 2021 - OF PRESSURE ULCER OR SDTI REPORTED where a pressure ulcer risk assessment was: Documented within 24 hours … commonly reported scenario involved the first pressure ulcer risk assessment Documented within 24 hours … The third most common scenario was a risk assessment Documented within 24 hours of admission and resulting … intracranial veins or sinuses, or splanchnic, portal or renal veins VTE that develops within 48 hours

2196. Final Progress Report: MOVES: Patient-Based Strategy To Reduce Errors in Diabetes Care (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/oconnor-report.pdf
      January 01, 2024 - Furthermore, no lipid assay results were reported unless the patient had been fasting for at least 10 hours

2197. Making Healthcare Safer Practices: 12. Infusion Pumps (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/infusion-pumps-1.pdf
      March 01, 2020 - Mixed-methods field study combining 9 hours of observation, formal interviews, and Cognitive Task

2198. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
      www.ahrq.gov/downloads/pub/advances/vol2/Schiff.pdf
      January 01, 2005 - standardizing protocols for reading x-rays/lab tests, particularly in training programs and after hours … laboratory tests (such as pathology specimens), particularly in residency training programs and “after hours

2199. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schiff.pdf
      January 01, 2005 - standardizing protocols for reading x-rays/lab tests, particularly in training programs and after hours … laboratory tests (such as pathology specimens), particularly in residency training programs and “after hours

2200. 030-Hand-Hygiene-Webinar-Slides-Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/030-hand-hygiene-webinar-slides-notes.docx
      October 01, 2024 - AHRQ Safety Program for MRSA Prevention Hand Hygiene Promotion ICU & Non-ICU Slide Title and Commentary Slide Number and Slide Hand Hygiene Promotion SAY: Welcome to this presentation about hand hygiene promotion and how it impacts MRSA prevention. This presentation will provide information about hand hygiene indi…