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psnet.ahrq.gov/issue/systematic-review-patient-safety-measures-adult-primary-care
March 15, 2016 - This systematic review identified 182 published safety measures in primary care and categorized them … The authors note several limitations with the metrics they identified—most had not been validated, and … there were no published measures identified for diagnostic error (despite increasing evidence that
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www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdf
January 01, 2024 - in a test environment prior to final comparison of identified
risks of chemotherapy administration … The
major components of the overall process were identified and flowcharted. … Potential failure identified from FMEA:
1.. … Potential failures identified from FMEA:
3.1 Illegible order RPN score: 80
3.2 Orders generated … Potential failures identified from FMEA:
5.1 OK to Give order generated by chemotherapy-certified
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psnet.ahrq.gov/node/43013/psn-pdf
March 12, 2014 - Laboratory test ordering and results management
systems: a qualitative study of safety risks identified … Laboratory test ordering and results management systems: a qualitative study
of safety risks identified … laboratory-test-ordering-and-results-management-systems-qualitative-study-
safety-risks
In this qualitative study, outpatient practice administrators identified
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/obsrounds.doc
June 02, 2025 - Were conflicts identified in the patient’s care plan?
· How were the conflicts resolved? … · Were changes in the day clearly identified?
· How were these changes resolved? … on your observations and the preceding questions, list any teamwork and communication problems you identified
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/measurespec-code-tables.pdf
June 05, 2025 - TCD Receipt of TCD screening is identified as the presence of at least one CPT code for TCD
screening … Diagnosis ICD-9: Children with sickle cell anemia are identified as those with sickle cell anemia-
related … ICD-10: Children with sickle cell anemia are identified as those with at least one
outpatient visit
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/action-plan-template.docx
April 01, 2022 - Complete one plan for each gap identified. … This can be accomplished by using this form multiple times to address all gaps identified. … Identified Gap (describe)
______________________________________________________________________
__
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www.ahrq.gov/ncepcr/reports/2024-annual-report/appendix-a.html
May 01, 2024 - additional search of AHRQ’s grant database (using the same fiscal years and search term), our team identified … AHRQ also shared a list of 29 contracts they identified as potentially related to primary care and were … the Abt team coded the top three key topic areas using areas of focus and interest that AHRQ had identified … These additional themes included areas of interest to AHRQ which were identified a priori, such as multiple … chronic conditions, telehealth, and women’s health/reproductive health, as well as themes identified
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/envscan-exec-summary.pdf
March 01, 2017 - They then identified articles for inclusion in the
Guide based on established inclusion and exclusion … Although the team identified policy-related factors,
they are beyond the scope of this project. … Much of the work identified draws on expert panel
recommendations, reports, and well-described case … Most of the materials identified were complex or had poor usability. … Many of the materials identified were at a literacy level or health literacy level that could
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Gallagher2.pdf
January 01, 2016 - Method: Using unique patient
identifiers in New York inpatient hospitalization data, patients identified … Finally, counts and rates
of patients identified with the area-level PSI were calculated. … Table 1 also shows the number of events identified with the area-level PSI
(7,373).
Table 1. … For patients identified as readmissions after a previous inpatient stay,
55.6 percent were renal or … The area-level indicator
identified 7,373 cases in New York State for 2001 (Table 1).
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/clabsi_invest-slides/CLABSI-Investigation-Walk-the-Process-Sept-14-2010-508.ppt
January 01, 2010 - When we identified this BSI, we treated as a defect because we believe we need to treat every BSI as … Lessons Learned
Attributable infection definition misunderstood
ICU taking credit for infections identified … Audit: Lessons Learned
One ICU’s central line infections associated with one particular provider
Identified … given additional training
Individual providers more comfortable with femoral site over IJ or SC
Identified … Process Audit: Lessons Learned
Charge RN found a dozen full-barrier drapes in a storage drawer
Identified
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www.ahrq.gov/research/findings/final-reports/ssi/ssiaps.html
April 01, 2018 - Content analysis was conducted using an inductive approach with initial topics mentioned by participants identified … Topics identified as duplicative were combined into a single occurrence. … A topic was identified as a theme if at least 3 participants mentioned or agreed with a topic. … Results: Multiple themes relevant to SSI risk stratification were identified and combined into 5 core … Current risk adjustment tools are too simple; evidence-based risk factors need to be identified and measured
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www.ahrq.gov/sites/default/files/wysiwyg/cpi/about/organization/nac/snac-hqm-report-exec-summary.pdf
November 17, 2021 - were
specifically asked (1) if they agreed with the four gaps in the field of quality measurement
identified … Overall, the NAC agreed with the identified
measurement gaps, strategies to address these gaps, and … Specifically, the NAC
identified that AHRQ’s mission includes access and affordability to healthcare … In addition to an expanded discussion on health equity, the NAC identified provider well-being
and … In addition to the four gap areas in the measurement field identified by
the SNAC (i.e., health equity
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www.ahrq.gov/patient-safety/reports/liability/corbett.html
August 01, 2017 - Results : Stakeholder groups identified common barriers and solutions to hospital-home transitional care … Conclusions : A wide range of stakeholders identified similar themes regarding barriers contributing … Approaches to address many of the identified barriers are available. … Participants were identified based on their membership in a stakeholder population. … Concepts to support the main themes were identified in each focus group.
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psnet.ahrq.gov/issue/characteristics-patient-care-management-problems-identified-emergency-department-morbidity
April 24, 2018 - Study
Characteristics of patient care management problems identified in emergency … Characteristics of patient care management problems identified in emergency department morbidity and … Characteristics of patient care management problems identified in emergency department morbidity and
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psnet.ahrq.gov/issue/analysis-near-misses-identified-anesthesia-providers-intensive-care-unit
August 17, 2017 - Study
An analysis of near misses identified by anesthesia providers in the intensive … An analysis of near misses identified by anesthesia providers in the intensive care unit. … An analysis of near misses identified by anesthesia providers in the intensive care unit.
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www.ahrq.gov/pqmp/measures/access-outpatient-speciality.html
August 01, 2021 - Additional Specialists Identified Through Alternate Source (PDF, 44 KB)
Section 6, Table 9. … Diagnostic Codes Used in Validity Testing (XLSX, 1.4 MB)
Appendix B: Examination of Credentials for Identified
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psnet.ahrq.gov/node/45101/psn-pdf
July 01, 2017 - This
systematic review identified 182 published safety measures in primary care and categorized them … The authors note several limitations with the metrics they identified—most had not
been validated, and … there were no published measures identified for diagnostic error (despite increasing
evidence that
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www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-measures-atlas/ccrm-atlasapd3.html
March 01, 2013 - If barriers were identified team members discuss possible solutions. … No if at least one barrier identified and no solution discussed. … NA does not apply if no barriers were identified.
10. … Strengths of family members are identified and discussed at the meeting. … Discharge is not identified as an option .
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs024977-dexheimer-final-report-2018.pdf
January 01, 2018 - Patients identified by the algorithm were screened by two epileptologists for surgical candidacy. … The NLP system increased the number of identified surgical candidates by
43% (N = 98 vs. 140; p = 2 … The NLP system identified 200 patients as potential
surgical candidates. … Of all
patients identified by the NLP system, 128/200 (64%) had DRE. … identified
surgical candidates by 43%.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
April 07, 2008 - The process mapping identified six major stages of the emergency C-section process: (1)
admission of … Ten failure modes were
identified with RPN values ranging from 40 to 720 points. … The participants of every
simulation identified this failure mode. … It links both
latent conditions and active failures that are typically not identified in FMEA. … However, despite this knowledge, many process flaws and team failures
were identified.