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  1. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/OConnor.pdf
    January 01, 2003 - In hospital settings misuse of a therapy may lead to adverse events in minutes to hours.
  2. www.ahrq.gov/sites/default/files/2024-05/anderson-thomas-report.pdf
    January 01, 2024 - Final Progress Report: Simulation to Support Competency-Based Training in Orthopedic Trauma 1. TITLE PAGE Title of Project: Simulation to Support Competency-Based Training in Orthopedic Trauma Principal Investigator and Team Members. Principal Investigators: Donald D. Anderson, PhD – Professor, Orthopedics & Rehab…
  3. www.ahrq.gov/sites/default/files/2024-12/doucette-report.pdf
    January 01, 2024 - Final Progress Report: Demonstration of Quality Improvement of Medication Therapy Management Services AHRQ Grant Final Report Project Title: Demonstration of Quality Improvement of Medication Therapy Management Services Principal Investigator: William R. Doucette, PhD Email: william-doucette@uiowa.edu (319) 335-8…
  4. www.ahrq.gov/sites/default/files/2024-07/ebeling-report.pdf
    January 01, 2024 - Final Progress Report: EMR Planning To Improve North Iowa Healthcare AHRQ Grant Final Progress Report Title of Project: EMR Planning to Improve North Iowa Healthcare Principal Investigator and Team (Steering Committee) Members: • Toni Ebeling (Principal Investigator), RN, MSN, formerly, Chief Executive Officer, …
  5. www.ahrq.gov/research/findings/nhqrdr/chartbooks/access/access-slides.html
    June 01, 2018 - Access to Health Care Chartbook: Slide Presentation National Healthcare Quality and Disparities Report Slide 1 National Healthcare Quality and Disparitites Report Chartbook on Access to Health Care May 2016 Slide 2 National Healthcare Quality and Disparities Report Annual report to Congress m…
  6. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
    December 01, 2017 - Facilitator Guide: Learning From Defects Through Sensemaking Slide Title and Commentary Slide Number and Slide Learning From Defects Through Sensemaking SAY: This module focuses on the process of Learning From Defects Through Sensemaking. Slide 1 Learning Objectives SAY: At the end of this module, you will …
  7. www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
    December 01, 2017 - Learning From Defects Through Sensemaking: Facilitator Notes AHRQ Safety Program for Surgery Slide 1: Learning From Defects Through Sensemaking Say: This module focuses on the process of Learning From Defects Through Sensemaking. Slide 2: Learning Objectives Say: At the end of this module, you w…
  8. 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, …
  9. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Emanuel_19.pdf
    February 20, 2008 - The Patient Safety Education Project: An international Collaboration The Patient Safety Education Project: An International Collaboration Linda Emanuel, MD, PhD; Merrilyn Walton, PhD; Martin Hatlie, JD; Denys Lau, PhD; Tim Shaw, PhD; Joel Shalowitz, MD, MBA; John Combes, MD Abstract The Patient Safety Edu…
  10. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Seagull_98.pdf
    April 07, 2008 - Pillars of a Smart, Safe Operating Room Pillars of a Smart, Safe Operating Room F. Jacob Seagull, MD; Gerald R. Moses, PhD; Adrian E. Park, MD Abstract Major gains in patient safety can be achieved through development of innovative approaches to the care of surgical patients. Investigators and clinicians have…
  11. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/addexercises.pdf
    August 08, 2025 - On-Time Pressure Ulcer Prevention: Facilitator Training—Additional Exercises AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Facilitator Training Additional Exercises Nutrition Risk Reports Information Exercises ........................................................................…
  12. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt3.pdf
    June 01, 2014 - QDR 2014: Chartbook for Hispanic Health Care, Part 3 Chartbook on Health Care for Hispanics Part 3: Trends in Access and Priorities of the National Quality Strategy 2014 National Healthcare Quality and Disparities Report | 41 PART 3: TRENDS IN ACCESS AND PRIORITIES OF THE NATIONAL QUALITY STRATEGY 2014 QDR Cha…
  13. www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-135-fullreport.pdf
    February 01, 2017 - SCD, and pneumococcal sepsis is known to progress from the onset of fever to death in fewer than 12 hours
  14. www.ahrq.gov/sites/default/files/2025-02/nance-report.pdf
    January 01, 2025 - The CEO of the hospital within 24 hours went to the family, fully disclosed and discussed the error
  15. www.ahrq.gov/sites/default/files/2024-01/thomas2-report.pdf
    January 01, 2024 - first with all the monitors, and a lot of things going on with the patient…and the workload and the hours
  16. www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-234-fullreport.pdf
    June 17, 2014 - Surgeon General estimated the effect on missed school time to be quite significant, at 51 million school hours
  17. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/implementing-guide.pdf
    March 01, 2017 - Safety Culture should be completed by all staff (whether employed or contracted) working at least eight hours
  18. www.ahrq.gov/hai/cauti-tools/archived-webinars/assess-adapt-transcript.html
    December 01, 2017 - So staff meetings, admin hours, like I said, lunch and learn.
  19. Paul Tedrick (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/assess-adapt-transcript.doc
    June 03, 2014 - So staff meetings, admin hours, like I said, lunch and learn.
  20. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings.pptx
    December 01, 2017 - Even a small amount of time, as little as 4 hours a month, can make a difference visible to the surgical

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