- 
                                        
www.ahrq.gov/sites/default/files/2024-02/herwaldt-report.pdf
January 01, 2024 - Since then, there 
have been no other incidents detected.
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/hospital/vtguide/guideref.html
July 01, 2018 - Preventing Hospital-Associated Venous Thromboembolism 
 References 
 
 
 
 
 Previous Page Next Page 
 
 Table of Contents 
 
 Preventing Hospital-Associated Venous Thromboembolism 
 Preface 
 Executive Summary 
 Chapter 1. The Framework for Improvement 
 Chapter 2. Analyze Care Delivery 
 Chapter 3. Outline the Eviden… 
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-litreview.docx
January 01, 2017 - References
Low Tidal Volume (Lung Protective) Ventilation Literature Review
Low tidal volume (lung-protective) ventilation (LTVV) is associated with decreased acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) progression as well as a shorter length of stay (LOS). The Society for Healthcare Epide… 
                                     
                                                                    - 
                                        
www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-lit-review.html
January 01, 2017 - Low Tidal Volume (Lung Protective) Ventilation Literature Review 
 
 
 
 
 
 
 
 
 
 AHRQ Safety Program for Mechanically Ventilated Patients 
 
 Low tidal volume (lung-protective) ventilation (LTVV) is associated with decreased acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) progression as well … 
                                     
                                                                    - 
                                        
www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guideref.html
July 01, 2018 - Preventing Hospital-Associated Venous Thromboembolism 
 References 
 
 
 
 
 Previous Page Next Page 
 
 Table of Contents 
 
 Preventing Hospital-Associated Venous Thromboembolism 
 Preface 
 Executive Summary 
 Chapter 1. The Framework for Improvement 
 Chapter 2. Analyze Care Delivery 
 Chapter 3. Outline the Eviden… 
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/findings.html
August 01, 2022 - explain what happened; use that knowledge to improve patient safety and prevent the recurrence of such incidents … present for our sites, including a commitment from physicians to collaborate with facilities to resolve incidents … Further, incidents of shoulder dystocia decreased 50 percent. 
 Shoulder dystocia-related claims.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Wilson.pdf
December 01, 2004 - Other patient safety incidents can be traced to the physician 
responsible for the episode of care when
                                     
                                                                    - 
                                        
www.ahrq.gov/research/findings/final-reports/ssi/ssi2a.html
April 01, 2018 - Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection 
 Chapter 2. Determine Surgical Site Infection Rates (continued) 
 
 
 
 
 Previous Page Next Page 
 
 Table of Contents 
 
 Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection 
 Executive S… 
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/delirium-1.pdf
March 01, 2020 - Making Healthcare Safer Practices: 14. Delirium
Delirium 14-1 
14. Delirium 
Authors: Lynn Hoffman M.A., M.P.H., Aline Holmes D.N.P., R.N., Jennifer Riggs, Ph.D., R.N., and 
Stephanie Schneiderman, M.P.P. 
Introduction 
Patient safety research and quality improvement efforts have been underway in the delirium harm … 
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/diagnostic-safety-resources.pdf
May 01, 2023 - This resource is a tool to help reduce patient safety incidents caused 
by actions during the diagnostic
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap3a.html
October 01, 2014 - Improving Patient Safety in Long-Term Care Facilities 
 Appendix 3-A. Suggested Slides for Module 3 
 
 
 
 
 Previous Page Next Page 
 
 Table of Contents 
 
 Improving Patient Safety in Long-Term Care Facilities 
 Introduction 
 Module 1. Detecting Change in a Resident's Condition 
 Module 2. Communicating Change in … 
                                     
                                                                    - 
                                        
www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/finalsummary/finalsummary4.html
September 01, 2015 - Key Lessons from the National Evaluation of the CHIPRA Quality Demonstration Grant Program 
 Improving service systems for youth with serious emotional disorders and their families 
 
 
 
 
 Previous Page Next Page 
 
 Table of Contents 
 
 Key Lessons from the National Evaluation of the CHIPRA Quality Demonstration Gr… 
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/publications/files/11-0060-EF.pdf
May 01, 2011 - stressed that, while reporting of patient safety events may often be associated with 
hospital-based incidents … ES-9 
 
Although reporting of patient safety events is often associated with hospital-based incidents … type of event that can be reported is often unspecified or described only in general terms such as 
incidents … an 
 
26 
 
external reviewer also cautioned that consumers are likely to identify and report incidents … discussed above, while 
reporting of patient safety events is often associated with hospitals-based incidents
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/consumer-experience/reporting/11-0060-EF.pdf
May 01, 2011 - stressed that, while reporting of patient safety events may often be associated with 
hospital-based incidents … ES-9 
 
Although reporting of patient safety events is often associated with hospital-based incidents … type of event that can be reported is often unspecified or described only in general terms such as 
incidents … an 
 
26 
 
external reviewer also cautioned that consumers are likely to identify and report incidents … discussed above, while 
reporting of patient safety events is often associated with hospitals-based incidents
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Baker.pdf
February 01, 2005 - ACRM)  
The value of ACRM resides in its realistic enactment using scenarios of 
operating room (OR) incidents … Anesthesia 
crisis resource management training: teaching 
anesthesiologists to handle critical incidents
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blegen.pdf
January 01, 2004 - Full reporting of incidents.  
d. Communication about safety threats.  
e. … Hospital safety climate and its relationship with safe 
work practices and workplace exposure incidents
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/reports/hotline/intro1.html
May 01, 2016 - Prompted reporting may lower the threshold for reporting without reducing the severity of reported incidents
                                     
                                                                    - 
                                        
www.ahrq.gov/research/shuttered/acfselection/appendixd.html
July 01, 2018 - Disaster Alternate Care Facilities: Report and Interactive Tools 
 Appendix D: Alternate Care Facility Questionnaire—Summary of Results 
 
 
 
 
 Previous Page   
 
 Table of Contents 
 
 Disaster Alternate Care Facilities: Report and Interactive Tools 
 Executive Summary 
 Chapter 1. Objectives 
 Chapter 2. Background… 
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Quinn.pdf
January 01, 2004 - Can an Academic Health Care System Overcome Barriers to Clinical Guideline Implementation?
291 
Can an Academic Health Care  
System Overcome Barriers to  
Clinical Guideline Implementation? 
Debra Quinn, Mary Cooper, Lynn Chevalier,  
Jerry Balentine, Lawrence Kadish, Steven Walerstein,  
Fredric Weinbaum, Mark Ca… 
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Seger.pdf
January 01, 2003 - A 
computerized method for identifying incidents 
associated with adverse drug events in outpatients.