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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
May 19, 2003 - Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis
323
Improving the Safety of Heparin
Administration by Implementing a
Human Factors Process Analysis
Kathleen A. Harder, John R. Bloomfield,
Sue E. Sendelbach, Michele F. Shepherd, Pam S. Rush,
Jamie S. Sinclair,…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
December 23, 2004 - Taxonomic Guidance for Remedial Actions
75
Taxonomic Guidance for Remedial Actions
Bruce Thomadsen, Shi-Woei Lin
Abstract
Objectives: This project developed a taxonomy to provide guidance in selecting
remedial actions to address problems uncovered during root cause analyses of
events in a medical setting. M…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Campbell_94.pdf
March 30, 2008 - Christiana Care Health System: Safety Mentor Program
Christiana Care Health System: Safety
Mentor Program
Michele Campbell, RN, MSM, CPHQ; Christine Carrico, RN, MSN, CPHQ; Carol Kerrigan
Moore, RN, MS, FNP-BC; Terri Lynn Palmer, MPA
Abstract
According to the Institute of Medicine, as many as 98,000 patients…
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
January 01, 2024 - Spotlight
Hindsight is 20/20: Thrombolytics for Alcohol
Intoxication
Source and Credits
• This presentation is based on the April 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Eric Signoff, MD, Noelle Boctor, MD, and David K.
B…
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psnet.ahrq.gov/node/866993/psn-pdf
October 30, 2024 - In Conversation with Elizabeth Salisbury-Afshar about
Harm Reduction Strategies to Improve Safety for People
Who Use Substances
October 30, 2024
Salisbury-Afshar E, Gale B, Mossburg S. In Conversation with Elizabeth Salisbury-Afshar about Harm
Reduction Strategies to Improve Safety for People Who Use Substances. P…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/exercises.html
December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention
Facilitator Training—Additional Exercises
Contents
Nutrition Risk Reports Information Exercises
Exercise #1: Risk Criteria and Rules
Exercise #2: Identify Residents Meeting High-Risk Criteria
Exercise #3: Identify Resi…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/c-7ARQE9RuXKjjpeLABkaH
March 01, 2007 - Aspirin or Nonsteroidal Anti-inflammatory Drugs for the Primary Prevention of Colorectal Cancer
Routine Aspirin or Nonsteroidal Anti-inflammatory Drugs for the
Primary Prevention of Colorectal Cancer: U.S. Preventive Services
Task Force Recommendation Statement
U.S. Preventive Services Task Force*
This statement sum…
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www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/execsumm.html
December 01, 2017 - ARRA ACTION: Comparative Effectiveness of Health Care Delivery Systems for American Indians and Alaska Natives Using Enhanced Data Infrastructure
Executive Summary
Previous Page Next Page
Table of Contents
ARRA ACTION: Comparative Effectiveness of Health Care Delivery Systems for American Indians an…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety.pptx
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety
AHRQ Safety Program for Perinatal Care
Labor and Delivery Unit Safety
AHRQ Publication No. 17-0003-21-EF
May 2017
1
Learning Objectives
2
AHRQ Safety Program for Perinatal Care
L&D Unit Safety
2
L&D Unit Safety Tools
The Labor and Delivery…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/tool_safe-mgso4.docx
May 30, 2013 - AHRQ Safety Program for Perinatal Care: Safe Medication Administration: Magnesium Sulfate
AHRQ Safety Program for Perinatal Care
Safe Medication Administration
Magnesium Sulfate
Safe Medication Administration—Magnesium Sulfate
Purpose of the tool: This tool describes the key perinatal safety elements with examples for…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/tap.html
October 01, 2014 - Designing and Implementing Medicaid Disease and Care Management Programs
Appendix: State Overviews
Previous Page Next Page
Table of Contents
Designing and Implementing Medicaid Disease and Care Management Programs
Introduction
Section 1: Planning a Care Management Program
Section 2: Engaging S…
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www.ahrq.gov/sites/default/files/2024-11/stulberg-report.pdf
January 01, 2024 - Final Progress Report: Preventing Opioid Misuse Through Safe Opioid Use Agreements Between Patients and Surgical Providers (PROMISE-ME)
TITLE PAGE
Title of Project:
Preventing Opioid Misuse through Safe Opioid Use Agreements between Patients and Surgical Providers
(PROMISE-ME)
Team Members:
Principal Investi…
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www.ahrq.gov/patient-safety/reports/advancing/index.html
July 01, 2022 - Advancing Patient Safety
A Decade of Evidence, Design, and Implementation
After the Institute of Medicine released its sentinel report, To Err is Human: Building a Safer Health System , the Agency for Healthcare Research and Quality (AHRQ), in conjunction with its Federal partners and non-Federal…
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www.ahrq.gov/sites/default/files/2024-01/robinson-papp-report.pdf
January 01, 2024 - Final Progress Report: Toward safer opioid prescribing for chronic pain in high risk populations
FINAL PROGRESS REPORT
1. TITLE PAGE
Title: Toward safer opioid prescribing for chronic pain in high risk populations: implementing the Centers for
Disease Control Guideline (CDC) guideline in the primary care HIV clini…
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www.ahrq.gov/sites/default/files/2024-01/brown-report.pdf
January 01, 2024 - Final Progress Report: Addressing Preventable Medication Use Variance in Mississippi
FINAL PROGRESS REPORT
Title of Project: Addressing Preventable Medication Use Variance in Mississippi
Principal Investigator: Brown, CA, MD, MPH
Team Members: William Rudman, PhD, Calvin Hewitt, MBA,
Honey Holman, MD, Kent Kirchn…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight11.pdf
September 08, 2015 - How are CHIPRA quality demonstration States using quality reports to drive heatlh care improvements for children? Evaluation Highlight No. 11
The CHIPRA Quality
Demonstration Grant Program
In February 2010, the Centers for Medicare &
Medicaid Services (CMS) awarded 10 grants,
funding 18 States, to improve the qu…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/factors-contributing-sustainment.pdf
August 31, 2015 - Factors Contributing to Sustainment Outcomes in Four States
1
Factors Contributing to Sustainment Outcomes in Four States
This supplementary material contains brief case studies that examine key factors influencing
decisions about sustaining elements of four states’ CHIPRA Quality Demonstration Grants. The …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pu_measurement.docx
January 01, 2016 - Module 5: How To Measure Pressure Injury Rates and Prevention Practices
Module 5: How To Measure Pressure Injury Rates and Prevention Practices
Module Aim
The aim of this module is to support your efforts to measure and monitor pressure injury rates and pressure injury prevention practices.
Module Goals
The goals of …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-icu-051314.pptx
February 07, 2014 - Slide 1
Preventing CAUTI in Specialized Patient Populations: The ICU
1
Hannah Wunsch, MD, MSc
Herbert Irving Assistant Professor of Anesthesiology and Epidemiology
Columbia University
Eugene Chu, MD, FHM
Director of Hospital Medicine
Boulder Community Hospital
Associate Clinical Professor of Medicine
University of Co…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
December 01, 2017 - Accessible Facilitator Guide: Learn From Defects for Sustainability
Slide Title and Commentary
Slide Number and Slide
Sustainability: Learning From Defects
SAY:
This module will review some concepts from Learning From Defects Through Sensemaking. It will also cover the Learning From Defects process from the per…