- 
                                        
www.ahrq.gov/patient-safety/reports/liability/crane.html
August 01, 2017 - "Every error counts": a web-based incident reporting and learning system for general practice. … The wrong diagnosis: identifying causes of potentially adverse events in general practice using incident
                                     
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/engage/leader.html
March 01, 2017 - Resident And Family Engagement: What is my role as a leader? 
 
 
 
 
 
 
 
 
 
 AHRQ Safety Program for Long-Term Care: HAIs/CAUTI 
 What is resident and family engagement? 
 
 Resident and family engagement is one component of person-centered care, a philosophy that recognizes residents as individuals and as partners… 
                                     
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/subglottic-factsheet.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Did You Know?
Continuous subglottic suctioning and frequent intermittent subglottic suctioning drainage of subglottic secretions, via a cuffed endotracheal tube, are associated with up to a 50 percent decrease in the incidence of gastric aspiration, a potential cause… 
                                     
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/overview.docx
March 01, 2017 - AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Long-Term Care Safety Toolkit Modules
Overview of the Long-Term Care Safety Toolkit Modules and Nursing Home Survey on Patient Safety Culture
The Long-Term Care (LTC) Safety Toolkit is designed to support learning and implementation efforts to improve safety cult… 
                                     
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cap-toolkit/cap_ed-pamphlet.pdf
January 01, 2018 - Community-Acquired Pneumonia in the Emergency Department Setting
Community-Acquired Pneumonia in the 
Emergency Department Setting
Background on Community-Acquired Pneumonia
Community-acquired pneumonia (CAP) is the eighth leading cause of death in the United States.1 Approximately 
6 million cases are reported annua… 
                                     
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar8_pu_sustainingpractices.pdf
April 01, 2011 - Sustaining Pressure Ulcer Prevention Practices at Your Hospital
Sustaining Pressure Ulcer 
Prevention Practices at 
Your Hospital
Presented by Dan Berlowitz, M.D., M.P.H.
Bedford VA Medical Center 
Boston University School of Public Health
2
Welcome!
Thank you for joining this
webinar about how to 
sustain pr… 
                                     
                                                                    - 
                                        
www.ahrq.gov/hai/cusp/modules/understand/science-safety-slides.html
July 01, 2018 - Understand the Science of Safety 
 
 
 
 Presentation Slides 
 The Understand the Science of Safety module of the CUSP Toolkit discusses the importance of understanding system design, safe design principles, and valuing diverse input from team members. By analyzing patient safety as a science, frontline providers will … 
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdf
May 01, 2017 - that occurred, teams 
reconstruct the timeline of the event by placing 
themselves in the midst of the incident
                                     
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/assess-psc-hsop-slides.pptx
January 01, 2017 - experience
Infection rates, sepsis
Respiratory failure 
Patient injury
Treatment errors
Clinician outcomes
Incident
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-patient-safety-culture-brief.pdf
September 01, 2016 - helps PSOs build trust is the set of legal 
protections for patient safety work product that protects 
incident
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapc.html
December 01, 2017 - Resident in her room alone at time of incident, attempting to get up out of chair unassisted-wants to
                                     
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www.ahrq.gov/hai/tools/mvp/modules/technical/sat-sbt-lit-review.html
January 01, 2017 - Spontaneous Awakening Trials and Spontaneous Breathing Trials Literature Review 
 
 
 
 
 
 
 
 
 
 AHRQ Safety Program for Mechanically Ventilated Patients 
 Summary 
 Spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) reduce the length of mechanical ventilation, thereby reducing the risk for de… 
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/sat-sbt-litreview.docx
January 01, 2017 - Tool: SSA
Summary
Spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) reduce the length of mechanical ventilation, thereby reducing the risk for developing ventilator-associated pneumonia (VAP). Since the guidelines were written in 2007, a groundbreaking article by Girard in 20081 showed that SA… 
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/datameasures-guide.pdf
January 01, 2017 - Data Measures Guide
AHRQ Safety Program for 
Mechanically Ventilated Patients 
 
 
 
Data Measures Guide 
 
AHRQ Pub. No. 16(17)-0018-6-EF 
January 2017 
 
 
Data Measures Guide 
Introduction ....................................................................................................................… 
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apv.html
June 01, 2010 - Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services 
 Appendix V: Tested Measures by DRA Domain 
 
 
 
 
 Previous Page Next Page 
 
 Table of Contents 
 
 Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services 
 Executive Summary 
 Introduction and S… 
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu4a.html
October 01, 2014 - Preventing Pressure Ulcers in Hospitals 
 4. How Do We Implement Best Practices in Our Organization? (continued) 
 
 
 
 
 Previous Page Next Page 
 
 Table of Contents 
 
 Preventing Pressure Ulcers in Hospitals 
 Overview 
 Key Subject Area Index 
 1. Are we ready for this change? 
 2. How will we manage change? 
 3.… 
                                     
                                                                    - 
                                        
www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu4a.html
October 01, 2014 - Preventing Pressure Ulcers in Hospitals 
 4. How Do We Implement Best Practices in Our Organization? (continued) 
 
 
 
 
 Previous Page Next Page 
 
 Table of Contents 
 
 Preventing Pressure Ulcers in Hospitals 
 Overview 
 Key Subject Area Index 
 1. Are we ready for this change? 
 2. How will we manage change? 
 3.… 
                                     
                                                                    - 
                                        
www.ahrq.gov/hai/cauti-tools/archived-webinars/preventing-cauti-specialized-populations-icu-slides.html
December 01, 2017 - Lists date & time of event 
 Cites NHSN criteria for event labeled as a CAUTI 
 Raises awareness of incident
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/intro.html
November 01, 2014 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention 
 
 
 
 Introduction 
 This document provides an overview of the components of On-Time Pressure Ulcer Prevention, reports, and implementation materials used in preventing pressure ulcers in nursing homes. On-Time Pressure Ulcer Prevention has be… 
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/engage/rfe-role-leader.pdf
March 01, 2017 - Resident and Family Engagement: What is my role as a leader?
 •  Resident and family engagement is one 
component of person-centered care, a 
philosophy that recognizes residents as 
individuals and as partners.
 •  Effective resident and family partnerships are 
demonstrated by including the residents and 
family a…