-
psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-improving-safety-iv-drug-administration
March 23, 2012 - The authors used failure mode and effects analysis (FMEA) to identify dosing and administration errors … 2012
Development of an online morbidity, mortality, and near-miss reporting system to identify … April 30, 2014
Using in situ simulation to identify and resolve latent environmental … December 21, 2014
Use of unsolicited patient observations to identify surgeons with increased
-
psnet.ahrq.gov/node/48060/psn-pdf
June 19, 2019 - Strategies to identify patient risks of prescription opioid
addiction when initiating opioids for pain … Strategies to Identify Patient Risks of Prescription Opioid Addiction
When Initiating Opioids for Pain … https://psnet.ahrq.gov/issue/strategies-identify-patient-risks-prescription-opioid-addiction-when-initiating … This systematic review sought to
identify factors that confer risk for opioid addiction and thereby … They could not identify any screening instruments or tools that
accurately risk-stratified individuals
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/applycusp.pptx
August 18, 2011 - regularly (weekly or at least monthly)
Has adequate resources
16
17
Engage the Senior Executive
Identify … three principles of safe design:
Standardize
Create independent checks
Learn from defects
20
Identify … Defects Through Sensemaking
Introduce CUSP and Sensemaking tools to identify defects or errors
Discuss … defects and identify ways to deter them from occurring in the future
The team should:
Share summaries … barriers to communication
Describe the connections between communication and medical error
Identify
-
www.ahrq.gov/patient-safety/resources/learning-lab/dream-lab-long-desc.html
August 01, 2025 - emergency departments. 1,2 The lab used a systems engineering framework and human-centered design to identify … The specific aims were to: Identify factors contributing to diagnostic errors and inappropriate clinical … Using patient experience surveys to identify potential diagnostic safety breakdowns: A mixed methods … Evaluation of a natural language processing approach to identify diagnostic errors and analysis of safety … Using patient experience surveys to identify potential diagnostic safety breakdowns: A mixed methods
-
psnet.ahrq.gov/node/855092/psn-pdf
November 08, 2023 - Using in situ simulation to identify latent safety threats in
emergency medicine: a systematic review … Using in situ simulation to identify latent safety threats in emergency medicine: a
systematic review … https://psnet.ahrq.gov/issue/using-situ-simulation-identify-latent-safety-threats-emergency-medicine- … https://psnet.ahrq.gov/issue/using-situ-simulation-identify-latent-safety-threats-emergency-medicine-systematic-review … https://psnet.ahrq.gov/issue/using-situ-simulation-identify-latent-safety-threats-emergency-medicine-systematic-review
-
psnet.ahrq.gov/node/837333/psn-pdf
June 08, 2022 - Hospital-wide cardiac arrest in situ simulation to identify
and mitigate latent safety threats. … Hospital-wide cardiac arrest in situ simulation to identify and
mitigate latent safety threats. … https://psnet.ahrq.gov/issue/hospital-wide-cardiac-arrest-situ-simulation-identify-and-mitigate-latent-safety … -
threats
In situ simulations are an effective method to identify latent safety threats (LST). … https://psnet.ahrq.gov/issue/hospital-wide-cardiac-arrest-situ-simulation-identify-and-mitigate-latent-safety-threats
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-gray-sops-action-planning-tool.pdf
June 02, 2025 - • Raise staff awareness about patient safety;
• Assess patient safety culture;
• Identify strengths and … • Identify initiatives
• Evaluate the options
• Select your initiative and define its scope
• Leadership … • Identify key people who will be affected
► Consider domino effects in other units
23
5. … • Identify a leader and/or champion
► Essential to identify enthusiastic, respected leader
and/or champion … • Identify barriers and how they can be overcome
► For example
− Satisfaction with the status quo
−
-
psnet.ahrq.gov/node/844548/psn-pdf
February 15, 2023 - Use of complete medication history to identify and correct
transitions-of-care medication errors at … Use of complete medication history to identify and correct
transitions-of-care medication errors at … https://psnet.ahrq.gov/issue/use-complete-medication-history-identify-and-correct-transitions-care- … medication-errors
Medication reconciliation can help identify medication discrepancies during transitions … https://psnet.ahrq.gov/issue/use-complete-medication-history-identify-and-correct-transitions-care-medication-errors
-
psnet.ahrq.gov/node/61066/psn-pdf
October 28, 2020 - Using event reports in real-time to identify and mitigate
patient safety concerns during the COVID-19 … Using event reports in real-time to identify and mitigate patient
safety concerns during the COVID-19 … https://psnet.ahrq.gov/issue/using-event-reports-real-time-identify-and-mitigate-patient-safety-concerns … 19
This article describes one academic medical center’s use of the Donabedian framework to rapidly identify … https://psnet.ahrq.gov/issue/using-event-reports-real-time-identify-and-mitigate-patient-safety-concerns-during-covid
-
psnet.ahrq.gov/node/45692/psn-pdf
January 01, 2020 - A patient reported approach to identify medical errors and
improve patient safety in the emergency department … A Patient Reported Approach to Identify Medical Errors and
Improve Patient Safety in the Emergency Department … https://psnet.ahrq.gov/issue/patient-reported-approach-identify-medical-errors-and-improve-patient-safety … They found that patients
were able to accurately identify adverse events and near misses, only a small … https://psnet.ahrq.gov/issue/patient-reported-approach-identify-medical-errors-and-improve-patient-safety-emergency
-
psnet.ahrq.gov/node/50836/psn-pdf
January 29, 2020 - Developing a cancer-specific trigger tool to identify
treatment-related adverse events using administrative … specific trigger tool to identify treatment?
related adverse events using administrative data. … https://psnet.ahrq.gov/issue/developing-cancer-specific-trigger-tool-identify-treatment-related-adverse … or prostate cancer investigated the feasibility of a
cancer-specific claims-based trigger tool to identify … https://psnet.ahrq.gov/issue/developing-cancer-specific-trigger-tool-identify-treatment-related-adverse-events-using
-
psnet.ahrq.gov/node/74229/psn-pdf
January 12, 2022 - A simulation systems testing program using HFMEA
methodology can effectively identify and mitigate latent … A simulation systems testing program using HFMEA methodology
can effectively identify and mitigate latent … //psnet.ahrq.gov/issue/simulation-systems-testing-program-using-hfmea-methodology-can-effectively-
identify-and … study, researchers used simulation training
and healthcare failure mode and effect analysis (HFMEA) to identify … https://psnet.ahrq.gov/issue/simulation-systems-testing-program-using-hfmea-methodology-can-effectively-identify-and
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-136-section-2-tables-1-3.pdf
June 02, 2025 - Internal Medicine
Pediatrics (Unspecified)
General Practice
Pediatric General Medicine
Table 2: Identify … Primary Care Visits
CAP-A: Codes to Identify Ambulatory or Preventive Care Visits
Description CPT … 99381-99385, 99391-99395,
99401-99404, 99411-99412,
99420, 99429
G0438, G0439
AAP-A: Codes to Identify … 99397,
99401-99404, 99411, 99412,
99420, 99429
Table 3: NCQA 2013 NDC List Used to Identify
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/sca-key-drive-diagram.pdf
June 02, 2025 - Identify MHP provider experts to help educate other
providers. … Identify exemplary pharmacies for providers and patients
Disperse 1-month supply of penicillin (1/2 … Process for clinic to create notarized care plans to identify
authorized caregivers. … Create and maintain patient registry to identify gaps in care
and enable QI processes. … Population health
approach to identify and
resolve clinical care gaps.
-
www.ahrq.gov/hai/tools/surgery/modules/implementation/ssi-bundle-slides.html
October 01, 2020 - Identify local barriers to implementation.
Measure performance. … Identify the barriers.
Summarize barrier information. … Activity: Identify roles for your ideal BIM Team. … Identify local barriers to implementation. … Identify and address local defects.
-
www.ahrq.gov/sites/default/files/publications/files/coe-workshopissuebrief.pdf
January 11, 2017 - The lack of
consistency in the terminology
used to identify health systems
and their component parts … and the variation in available
datasets to identify systems
create challenges to studying
comparative … A number
of challenges arise when using
existing data to identify health
systems. … • Linkage variables are needed
to integrate data that
identify health systems with
performance … RAND is similarly starting
from the physician
organization level to identify
hospital affiliations
-
psnet.ahrq.gov/node/50751/psn-pdf
December 18, 2019 - Using a machine learning system to identify and prevent
medication prescribing errors: a clinical and … Using a machine learning system to identify and
prevent medication prescribing errors: A clinical and … https://psnet.ahrq.gov/issue/using-machine-learning-system-identify-and-prevent-medication-prescribing … -
errors-clinical-and
Clinical decision support (CDS) tools help identify and reduce medication errors … https://psnet.ahrq.gov/issue/using-machine-learning-system-identify-and-prevent-medication-prescribing-errors-clinical-and
-
psnet.ahrq.gov/node/74001/psn-pdf
January 01, 2022 - Filling a gap in safety metrics: development of a patient-
centred framework to identify and categorise … Filling a gap in safety metrics: development of a patient-
centred framework to identify and categorise … https://psnet.ahrq.gov/issue/filling-gap-safety-metrics-development-patient-centred-framework-identify-and … This study
brought patients, families, clinicians and experts together to identify patient-reported … https://psnet.ahrq.gov/issue/filling-gap-safety-metrics-development-patient-centred-framework-identify-and-categorise
-
www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-11.html
November 01, 2014 - Identify at least one primary measure of success.
Create a project scope. … Identify the key players and engage them. … Project
Identify the key players and engage them. … Identify the customers of the work process or flow and determine how they define value. … Analyze the work process or flow and identify improvement opportunities.
-
www.ahrq.gov/hai/cusp/modules/apply/sl-cusp.html
December 01, 2012 - Identify Defects Through Sensemaking
Slide 22. … Identify Defects Through Sensemaking
Introduce CUSP and Sensemaking tools to identify defects or … CUSP and Sensemaking tools help teams identify defects and identify ways to deter them from occurring … Identify barriers to communication. … Identify and apply effective communication strategies from CUSP and TeamSTEPPS®.