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Showing results for "how to do a case study".

1781. AHRQ National Scorecard on Hospital-Acquired Conditions: Final Results for 2014 Through 2017 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/Updated-hacreportFInal2017data.pdf
      July 01, 2020 - The decrease in HACs from 2014 to 2017 based on a slightly different method showed a 13 percent reduction … A powerful foundation of knowledge about how to improve patient safety has been established over more … The details of how the current NHR is calculated are summarized below. 1. … Due to changes in how some conditions and adverse events are described in ICD-9 and ICD-10, the data … It is notable that because MPSMS is based on chart-abstraction, results do not depend on this coding

1782. Rapidresponse Facguide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse_facguide.docx
      May 01, 2017 - Slide 1 SAY: In this module, we will do the following: Define components of a rapid response system … A rapid response system is more than a team that responds to emergencies. … rapid response system to determine how the elements will be implemented within a hospital. … Engagement In the rest of this presentation, we will highlight each of these key safety elements and how … One consideration is establishing a standard unitwide approach for responding to a request for a rapid

1783. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
      January 01, 2004 - Implementation Issues discussed by the medication subcommittee included the following: • What do … • Do we want to incorporate national standards? … Organizations that do not have 24-hour pharmacy services need to develop procedural barriers to prevent … Failure-to-rescue events Failure-to-rescue is defined as a situation in which a patient develops a … Identifying weak system fixes and providing information about how to strengthen them will facilitate

1784. From Public Testimony to Vehicle for Statewide Action: Experience of the Michigan State Commission on Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Valade_46.pdf
      May 05, 2008 - healing; they do not go to work intending harm. … of how and why the Commission’s process led to the results it did. … Because there are no absolute rules for how to implement a qualitative analytic approach, only standards … These “to-do” lists—too long to reproduce here—provide the roadmap to accomplishing the objective(s) … Even so, only 77 (28 percent) of 270 entities invited to submit testimony chose to do so.

1785. Low Tidal Volume Ventilation: Introduction, Evidence, and Implementation: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-intro-slides.html
      February 01, 2025 - Low tidal volume ventilation is a lung protective strategy that seeks to  prevent ventilator-associated … Slide 43: Address Variability in Practice Do you have a standardized protocol? … If a provider orders settings outside of LTVV strategy parameters, is a change to the order required? … How is the order modified? Do your providers comply with protocols? … Slide 44: Steps to Implementing a LTVV Strategy Educate staff on LTVV strategy.

1786. Person-Centered Preventive Healthcare: Reaching Adolescents to Deliver Preventive Services (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/research/reaching-adolescents-full.pdf
      April 01, 2024 - understand how to scale, evaluate, and sustain interventions that have been shown to have a positive … how to disseminate successful strategies and scale them to a larger population. … Well, this is a problem, I know! But you know, what can I do about it?’” … how to disseminate successful strategies and scale them to a larger population. … for services that reach youth who do not have regular encounters to primary care for a range of reasons

1787. Final Progress Report: Diagnostic Error in Medicine Annual Conference (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/trowbridge-report.pdf
      January 01, 2025 - by grant number 1R13HS024883-01, and its contents are solely the responsibility of the authors and do … is to bring together experts from a diverse array of fields to set the research agenda and identify … To Err is Human: Building a Safer Healthcare System. … Plenary Presentation: Purchaser and Consumer Perspectives on Improving Diagnosis • Panel Discussion: How … Performance • Technology Plenary: Diagnostic Technology and Medical Education • Plenary Presentation: How

1788. Preface | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/advances/preface.html
      July 01, 2022 - Although the Institute of Medicine's (IOM) 1999 report, To Err Is Human: Building a Safer Health System … errors occur and how to prevent them. … to work to improve patient safety. … improve patient safety, we have much more to do. … In addition to articles with a research and methodological focus, the volumes include a series of articles

1789. Labor and Delivery Unit Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.pdf
      May 01, 2017 - Slide 1 SAY: In this presentation, we will do the following: • Describe the rationale for the use … The sample checklists provided are examples of how key safety elements can be operationalized in a … necessary to respond quickly to a hemorrhage.19,20 • The use of a standardized approach for active … related to a team approach to cord prolapse. … • Review the key safety elements with L&D leadership and relevant staff • Determine how the elements

1790. Executive Summary | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/summary.html
      August 01, 2022 - How can a reporting system maximize the willingness and ability of consumers to report on patient safety … how these design features may be organized within a consumer reporting system, and a discussion of limitations … How can a reporting system maximize the willingness and ability of consumers to report on patient safety … In one model, systems do not expend resources to conduct RCAs, but request RCAs when performed by other … How can a reporting system maximize the willingness and ability of consumers to report on patient safety

1791. Executive Summary | Agency for Healthcare Research and Quality
      www.ahrq.gov/data/apcd/envscan/summary.html
      June 01, 2017 - Interest is growing in how to leverage APCD data for consumer-facing Web sites for price transparency … Catalyst for Payment Reform is a nonprofit organization that brings the perspective of purchasers to … The Health Care Cost Institute is a nonprofit organization whose goal is to provide access to health … Indication whether the condition is “shoppable” Indication of a quality measure to pair with a cost … to stakeholders and feasible to implement on a large scale.

1792. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Electronic Fetal Monitoring
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring.pptx
      May 01, 2017 - , intimidation, and failure to function as a team. … Safety Program for Perinatal Care Electronic Fetal Monitoring 6 Safe EFM Tool Purpose Who should use How … FHR tracings Activating a rapid response when— Provider is not immediately available to respond to some … Do timely and appropriate clinical responses occur with respect to EFM findings? … Any adaptations of this resource must include a disclaimer to this effect.

1793. II. Hotline Design and Development | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/hotline/design2.html
      May 01, 2016 - [text box] Why do you think this happened? … Complete instructions on how to audit or scrub a report, which prepares it for being shared, are given … consumers to finish their reports, even if the following structured items do not appear to be responsive … by a health care organization do not qualify for the privilege and confidentiality protections of the … i The Flesch-Kincaid reading scale is a tool designed to test how difficult a reading passage is to

1794. Final Progress Report: Reduction of Nephrotoxic Medication-Associated Acute Kidney Injury in Children (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/goldstein-report.pdf
      January 01, 2024 - application of how hospitals are utilizing quality improvement science to address factor that contribute … For example, we do not expect that there is just one way to effectively implement NINJA. … Qualitative comparative 10 https://www.himss.org/what-we-do-solutions/digital-health-transformation … both the different contextual factors that affect how NINJA is to be implemented as well as the different … Improving quality: how a hospital reduced medication errors. 2008. 30.

1795. Compendium of U.S. Health Systems, 2023, Technical Documentation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/2023-compendium-techdoc.pdf
      January 01, 2023 - not be comparable to how we count total physicians in AHA data, and (2) they may not be comparable … sequentially applied three criteria to exclude systems that do not have a qualifying hospital or comprehensive … not be comparable to how we count total physicians in AHA data, and (2) they may not be comparable … to how we count primary care physicians reported in the OneKey data, in which we include physicians … However, we do not have reason to think this type of misidentification was common.

1796. 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 - do if a dose is missed; includes assessing ability to adhere, allergy info, meds from other physicians … Some physicians indicated they do not take the time to look up needed drug information because the information … Further study should be conducted to determine how this need is best met. … on how they might accomplish this. … A minority of offices reported using published error experiences (e.g., case reports) from other sources

1797. Follow-up Practice Survey Codebook Including Core and Optional Items (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/survey-codebook-post-intervention.pdf
      June 02, 2025 - We suggest you designate an Office Manager or a Lead Clinician to complete this survey. … ……… 1 = yes 2 = no Moved to a new location prac_change_newlocation….. 1 = yes 2 = no Lost one or more … Next, we would like to understand how your practice uses registries and clinical guidelines for cardiovascular … How does your practice intend to meet the requirements of the Quality Payment Program? … On a scale from 1 to 10 where one is no priority at all and 10 is the highest priority, what is the

1798. Systemwide Deployment of Medical Team Training: Lessons Learned in the Department of Defense (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/King.pdf
      January 01, 2002 - King, Beth Kohsin, Mary Salisbury Abstract Advancing to a culture of safety requires a systems change … actions necessary for a group to transform from a cluster of people working independently into a team … Acknowledgments The views in this paper are those of the authors and do not necessarily represent … The heart of change: real life stories of how people change their organizations. … DoD Medical team training programs: an independent case study analysis.

1799. Chapter 6. Discussion and Policy Implications | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter6.html
      August 01, 2022 - patient safety events from occurring and understand the causes of events that do occur, regardless of … each system; pilot testing will be needed to assess how best to implement system design features given … How will the efficiency, costs, and benefits of a system be demonstrated? … How will staff be selected? How will training be designed and accomplished? … are allowed to access these data and how access is prevented for unauthorized personnel.

1800. Final Progress Report: Inpatient Provider Rounding Prioritization of Patients Ready for Discharge (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/burden-report.pdf
      January 01, 2024 - , we aimed to also understand how team composition and census impact fidelity to the model and discharge … a Medicine service, and assigned by standard practice to a general medical hospitalist team 4. … not able to adhere to their assigned randomization during a shift. … some clinicians do practice the ‘rounding on discharging patients first’ model. … Potential future areas of study will be on how workloads may influence these measures. 6.