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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schyve.pdf
June 02, 2025 - Prologue—Volume 2—Systems Thinking and Patient Safety
1
Prologue
Systems Thinking and Patient Safety
Paul M. Schyve
Patient safety is a prominent theme in health care delivery today. This should
come as no surprise, given that “first, do no harm” has been the ethical watchword
throughout the history of medi…
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www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-mar2023.pdf
July 14, 2023 - Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare
Federal Interagency Workgroup:
Improving Diagnostic Safety and Quality in Healthcare
March Meeting Summary
Workgroup Goal: Established in response to Senate Report 115-150. The Senate Committee on
Appropriations requested “AHRQ t…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
April 01, 2025 - Learning From Defects
Learning From Defects
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
AHRQ Pub. No. 25-0029
April 2025
AHRQ Safety Program for MRSA Prevention: Targeting SSI
AHRQ Safety Program for MRSA Prevention | Surgical Services
Learning From Defects
1
Educat…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4i_combo_psi12-dvt-bestpractices.pdf
May 20, 2016 - Selected Best Practices and Suggestions for Improvement
Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
Tool D.4i 1
Selected Best Practices and Suggestions for Improvement
PSI 12: Perioperative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT)
Why Focus on DVT/PE…
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www.ahrq.gov/sites/default/files/2024-01/schade-willis-report.pdf
January 01, 2024 - Final Report: Regional Patient Safety Officer Conference—Learning Together Today and Tomorrow
Conference Final Report
Regional Patient Safety Officer Conference – Learning Together Today and Tomorrow
Prepared for:
Agency for Healthcare Research and Quality
Project Officer:
William Freeman, MPH
Health Scientist …
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January 01, 2025 - SOPS Bibliography
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-plan-b-110414.pptx
January 01, 2013 - Antiseptic-impregnated catheters: Is the Juice Worth the Squeeze?
Preventing CAUTI:
What to Do When it’s Time for Plan B
Sanjay Saint, MD, PhD
George Dock Collegiate Professor of Internal Medicine
Division of General Medicine
University of Michigan Health Systems
Associate Chief of Medicine, Ann Arbor VA Medical Cent…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/sustainability/premortem-scorecard-slides.pptx
January 01, 2017 - Presentation: Tools for Sustainability: Premortem and Scorecard
Tools for Sustainability:
Premortem and Scorecard
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-39-EF
January 2017
Sustainability Tools ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
1
Learning Ob…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/surgical-complication-prevention/bim.docx
December 01, 2017 - Barrier Identification and Mitigation Tool
AHRQ Safety Program for Surgery
AHRQ Safety Program for Surgery
Barrier Identification and Mitigation Tool
Introduction
Problem Statement
Guidelines summarizing evidence exist to help ensure that patients receive recommended interventions. In addition, consistent guidel…
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www.ahrq.gov/hai/tools/surgery/tools/surgical-complication-prevention/bim.html
December 01, 2017 - Barrier Identification and Mitigation Tool
AHRQ Safety Program for Surgery
Introduction
Problem Statement
Guidelines summarizing evidence exist to help ensure that patients receive recommended interventions. In addition, consistent guideline adherence may significantly improve patient safety…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/129-ss-blank-lfd.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Learning From Defects Tool
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
What Is a Defect?
A defect is any clinical or operational event or situation that you would not want to happen again. This could include incidents…
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www.ahrq.gov/research/findings/final-reports/iomracereport/reldataapi.html
September 01, 2018 - Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement
I. Subcommittee Template: Developing a National Standard Set of Spoken Language Categories and Coding
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Race, Ethnicity, and Language Data: Standardization for Health Care …