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psnet.ahrq.gov/issue/project-jessica
September 16, 2020 - Audiovisual
Do No Harm: Jess's Story. … This video chronicles how an undiagnosed heart condition led to a teenager's death and offers tips … coronavirus 2019: a checklist to facilitate disclosure. … September 28, 2016
Mortality review as a tool to assess the contribution of healthcare-associated … infections to death: results of a multicentre validity and reproducibility study, 11 European Union
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www.ahrq.gov/sites/default/files/2024-12/cook-hoas-report.pdf
January 01, 2024 - textual analysis of
responses to case studies. … structured case study format. … Each case study was emailed directly to the research participants who were
asked to respond to a series … The use of case studies seemed to offer a way to achieve system change. … The curriculum, wrapped in a case study modality, seemed to overcome, and
bring to the fore, some of
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/autism-adolescents_disposition-comments.pdf
August 27, 2012 - case reports. … We did not exclude any study designs except
single case reports. … Because there is no separate comparison
group in these studies they would be considered
case reports … In addition, noncomparative designs
such as case reports or case series do not provide
direct evidence … In addition, noncomparative designs
such as case reports or case series do not provide
direct evidence
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www.ahrq.gov/cahps/consumer-reporting/guidelines/evaluation/index.html
March 01, 2016 - can help sponsors and their vendors assess how effectively they achieved their goals. … do during the report development stage to ensure that their choices—with regards to content, graphic … taking the time to submit a thoughtful critique of what confused them or failed to engage them. … How to Evaluate
Several methods are available for evaluating quality reports, some more affordable … Do Medicaid and commercial CAHPS scores correlate within plans?: a New Jersey case study.
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psnet.ahrq.gov/issue/learning-failure-need-independent-safety-investigation-healthcare
September 24, 2018 - leaders of nursing homes negotiate their dual responsibilities- a case study. … February 28, 2024
Leading quality and safety on the frontline - a case study of department … May 15, 2024
Investigating hospital supervision: a case study of regulatory inspectors … and requirements for complying with quality and safety regulation in nursing homes - a case study. … June 9, 2021
First do no harm: practitioners' ability to 'diagnose' system weaknesses
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www.ahrq.gov/hai/tools/mvp/modules/cusp/build-business-case-fac-guide.html
February 01, 2017 - how this safety program can affect the hospital’s financial bottom line, list the elements of a strong … Slide 8: VAPs Among Most Expensive HACs
Ask:
Do you know how much preventable healthcare-acquired … Slide 9: What Do We Need To Do? … This model is probably familiar to most health care workers, but it doesn’t always mean "do more with … The CFO, who typically has a degree in finance, understands how revenue is flowing and serves as the
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www.ahrq.gov/sites/default/files/publications/files/ltcinstructor.pdf
June 01, 2012 - lnstructor.indd 11 6/26/12 11:12 AM
12
Case Study
Ms. … Case Study: Ms. … Case Study: Ms. A
› How did Ms. A get so sick with only diarrhea? … A new instructor,
however, may prefer to keep the focus on a familiar case.
Case Study
Mr. … Case Study: Mr. P
› What are his risk factors for falling?
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psnet.ahrq.gov/issue/reduction-medication-errors-related-sliding-scale-insulin-introduction-standardized-order
June 19, 2024 - Insulin is known to be a high-risk medication. … This study demonstrates how standardization can support patient safety. … reports of diagnostic errors. … June 19, 2024
Diagnostic errors in uncommon conditions: a systematic review of case reports … February 14, 2018
Effectiveness of a 'Do not interrupt' bundled intervention to reduce
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan-aspirin-to-prevent-cardiovascular-diseas/aspirin-to-prevent-cardiovascular-disease-and-cancer-april-2016
October 07, 2013 - The figure illustrates how regular aspirin use in patients without known cardiovascular disease may result … in a decrease in myocardial infarction, ischemic stroke, and mortality related to all causes and cardiovascular … Do these cardiovascular risk prediction tools vary by subgroup? … clinical trials; large prospective cohort studies
KQ 1: Observational studies (cohort, case control, case … studies, or case series)
KQ 2: Case-control, case studies, or case series
Setting
Outpatient
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case4.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Case 4. … Studies
Introduction to the Case Studies
Case 1. … The case study methods, including selection criteria for projects to be analyzed, have been described … So then that went into a whole other process walk of how you clean a toilet? How you clean a sink? … they give care, how they do their processes.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap3a.html
October 01, 2014 - How falls can be prevented. … How nursing assistants and licensed nurses can work together to prevent falls. … Slide 3
Case Study: Mr. P
What are his risk factors for falling? … Slide 14
Pitfalls
Forgetting to do a falls assessment for a resident. … Failing to make a new falls assessment and care plan for a resident who has fallen.
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-5-implementation-guide.pdf
June 02, 2025 - • Who will do the testing?
• How will the testing be performed? … “Case Study: Self-Referral of Patient to a Cardiac Rehabilitation Program, Massachusetts General
Hospital … “Case Study: Referral of Patient to External Cardiac Rehabilitation Program, Massachusetts General
Hospital … The case study includes examples of fax cover sheets and other forms
used to facilitate these referrals … timestamp=1525103139064
This case study summarizes efforts by NYU Langone Health to establish a system-wide
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psnet.ahrq.gov/issue/patients-conceptualizations-responsibility-healthcare-typology-understanding-differing
January 08, 2020 - Yet, how patients perceive the responsibility for achieving safety remains poorly understood. … better understand how they attribute responsibility for their safety in the health care setting. … to care home transitions: a retrospective content analysis. … Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case … studies.
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psnet.ahrq.gov/issue/am-i-right-when-i-am-sure-data-consistency-influences-relationship-between-diagnostic
March 18, 2013 - their diagnosis was and how certain they felt. … prospective observational case study of five teaching hospitals. … September 1, 2019
A patient safety approach to setting pass/fail standards for basic … January 9, 2014
Teaching about how doctors think: a longitudinal curriculum in cognitive … September 18, 2013
Do you have to re-examine to reconsider your diagnosis?
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psnet.ahrq.gov/issue/how-organisations-contribute-improving-quality-healthcare
June 25, 2014 - Commentary
How organisations contribute to improving the quality of healthcare. … How organisations contribute to improving the quality of healthcare. … How organisations contribute to improving the quality of healthcare. … February 20, 2019
How do hospital boards govern for quality improvement? … December 1, 2010
Case study: getting boards on board at Allen Memorial Hospital, Iowa
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www.ahrq.gov/sites/default/files/2024-05/johnson-ying-report.pdf
January 01, 2024 - For the two strategies not
recommended for simulation, the use of written case studies was recommended … Observing a case study was recommended by six of the experts as the
teaching approach best suited for … experiences and case studies that addressed the interruption
management strategies per the Delphi … As the nurses were already in the classroom, our education began with a
written case study assessment … Following this observed case study, the participants
were debriefed and discussion about the case study
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/just-in-case-mindset.pdf
April 01, 2022 - • Provide education using case studies that incorporate catheter indications and strategies for … • Consider a best practice alert when criteria are no longer met with a reminder of how many
days … • Provide education and use patient case studies with all healthcare providers to address the
potential … Case Studies, Tools, and Resources
• Learn From Defects Tool Worksheet: CAUTI
• Learn From Defects … Leadership)
Conversation Starters
Case Studies, Tools, and Resources
References
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psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - It's a matter of how do you get people to understand this? … leaders of nursing homes negotiate their dual responsibilities- a case study. … February 28, 2024
Leading quality and safety on the frontline - a case study of department … May 15, 2024
Investigating hospital supervision: a case study of regulatory inspectors … and requirements for complying with quality and safety regulation in nursing homes - a case study.
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psnet.ahrq.gov/issue/hospital-board-and-management-practices-are-strongly-related-hospital-performance-clinical
October 27, 2021 - As many hospital boards still do not prioritize patient safety, these results help identify management … 1,500 avoidable deaths a year—and aim to do even better. … March 2, 2016
Post event debriefs: a commitment to learning how to better care for patients … January 13, 2016
Exploring the role of communications in quality improvement: a case … study of the 1000 Lives Campaign in NHS Wales.
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-guidance-harms_methods.pdf
November 01, 2008 - studies,
30
but can refer to a broad range of study designs, including case reports,
uncontrolled … Case reports and postmarketing surveillance. … A 1982 study examined 47 case reports published in 1963 in four
major general medical journals and … A recent study, in fact, found that
only 18 percent of case reports of suspected adverse drug reactions … Criteria for evaluating the likelihood of a causal relationship in case reports
Temporal relationship