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21. Outpatient Surgery and Patient Safety—The Patient’s Voice (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Hundt.pdf
    January 01, 2003 - In most instances, outpatient surgery centers are entities that depend on their surgeon base for referrals … performed elsewhere and surgery centers can be unaware of their patient outcomes—except for those instances … In all instances, participants reported receiving instructions. … In various instances participants stated that experience from a prior operation helped them to be better … In most instances the initial surgical experience was less than optimal, which caused them to become

22. Vermont Health Clinics Promote AHRQ’s Medication Safety Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/202003.html
    June 01, 2020 - For example, there were "several instances where patients didn't realize a medication had dropped off

23. Leveraging popHealth® and an active open source community to improve heart health in small-­ to medium-sized practices (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/evaluation/osehra-pophealth-20160629.pdf
    March 11, 2019 - performed • Benchmarking and scaling planned           Data  Loading • "Standards" – in some instances

24. Summary Skills Practice Exercise Sheet (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module7/ts2-0ltc_module7_ig_summary_exsheet.pdf
    April 24, 2017 - Identify the instances where a breakdown in teamwork has occurred as it relates to the specific teamwork

25. Step-by-Step Installation Guide for MONAHRQ (pdf file)
    www.ahrq.gov/downloads/monahrq/pdf/MONAHRQStepbyStepInstallation.pdf
    April 05, 2010 - Step-by-Step Installation Guide for MONAHRQ Step-by-Step Installation Guide for MONAHRQ Version 1.0 April 5, 2010 1 INTRODUCTION MONAHRQ is a free Windows-based software product that enables host users—such as State and local data organizations, charter…

26. NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
    November 01, 2021 - In some instances, receiving units did not have beds or staffing available to receive the … In several instances, the exposure occurred because staff were not following PPE protocols, such as … 19 PHE for front-line staff, and the effective communication of those changes played a role in some instances … In other instances, the increased workloads experienced by hospital staff and laboratories may have … In two instances, adverse reactions to medications used to treat COVID-19 were identified.

27. Running Effective Meetings and Creating Capacity for Practices to Run Effective Meetings (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-22-meetings.pdf
    September 01, 2015 - Although leaders have primary responsibility for the content of the meeting, in many instances, they … In these instances, you contribute to the discussions along with other participants. Observer. … Simple is often the best in these instances. … In these instances, it is important to intervene in a calm, respectful manner. … Simple is often the best in these instances. A tried-... Managing conflict during meetings.

28. Advancing Diagnostic Safety: An AHRQ Leadership Conversation | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-conversation.html
    October 01, 2021 - But we know that in many instances this just doesn’t happen.

29. Pediatric Measure: Primary Care Assessment Tool—Child Edition (PCAT-CE) | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/pcpaccountability/pcpacc1.html
    October 01, 2014 - Although the instrument was designed for accountability purposes, all published instances of use identified … Although the instrument was designed for accountability purposes, all published instances of use identified

30. PowerPoint Presentation (ppt file)
    www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T4-Common_Suspected_Infections_Tools_to_Improve_Communication_and_Decision_Making.ppt
    May 01, 2014 - be used for ALL situations when a resident has a new problem and infection may be suspected In those instances … /staff education is important because some people assume antibiotics are the right treatment in all instances … Distributed to current and new residents When hospice is considered Primary purposes educate about instances

31. Module 1: Overview | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/mod1.html
    February 01, 2023 - Slide 9: Consensus Narration: In some instances, you might need to do a daily urine volume measurement … Slide 12: Technical Challenges Narration: In some instances, resistance to changing catheter use

32. Intro (pdf file)
    www.ahrq.gov/downloads/monahrq/pdf/MONAHRQv204StepbyStepInstallation.pdf
    March 19, 2012 - Intro Step-by-Step Installation Guide for MONAHRQ Version 2.0.4 March 19, 2012 2 INTR ODUC TION MONAHRQ is a free Windows-based software product that enables host users—such as state and local data organizations, chartered value exchanges, hosp…

33. At the American Society of Health Economists Conference, AHRQ to Highlight Its Deep Dive into COVID-19 | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/blog/ahrqviews/deep-dive-into-covid19.html
    June 01, 2023 - essential to inform ongoing efforts to address the fragmentation and misaligned incentives that in many instances

34. Wisconsin Critical Access Hospital Sees Big Results with AHRQ’s CUSP, RED and TeamSTEPPS® | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/201520.html
    July 01, 2015 - component of CUSP, motivated hospital leaders to address SSI rates that approached 25 percent in some instances

35. Albuquerque Police Department Uses AHRQ Resources for Crisis Intervention Team Training | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/201708.html
    May 01, 2017 - The training has focused attention to instances when jail diversion is appropriate, because the individual

36. Final Progress Report: Brief, Risky, High-Benefit Procedures: Best Practice Model (pdf file)
    www.ahrq.gov/sites/default/files/2024-02/mackenzie-report.pdf
    January 01, 2024 - Whether the SMEs were physically present was noted; in all but a few instances, they were co-located … Two operators worked on each side of the chest, in some instances using only one surgical instrument … manipulation before insertion than the more expert operators. 4) Preparatory tasks were cut short in some instances … There were 113 instances of contamination in the 25 emergency chest tube insertions and 50 instances … In six instances, the unrestrained hand of the patient contaminated the surgical site.

37. Intro (pdf file)
    www.ahrq.gov/downloads/monahrq/pdf/MONAHRQ_v3_StepbyStepInstallationGuide-4.0.pdf
    June 01, 2012 - Intro Step-by-Step Installation Guide for MONAHRQ Version 3.0 June 2012 2 INTRODUCTION MONAHRQ is a free Windows-based software product that enables host users—such as state and local data organizations, chartered value exchanges, hospitals, and health pl…

38. Intro (pdf file)
    www.ahrq.gov/downloads/monahrq/pdf/MONAHRQ_v3_StepbyStepInstallationGuide.pdf
    June 01, 2012 - Intro Step-by-Step Installation Guide for MONAHRQ Version 3.0 June 2012 2 INTRODUCTION MONAHRQ is a free Windows-based software product that enables host users—such as state and local data organizations, chartered value exchanges, hospitals, and health pl…

39. Module 4: Teamwork and Communication: Material Use Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/guide.html
    March 01, 2017 - Staff will be asked to share instances when they have/could have used the tool.

40. Maryland Guides Prescribers on Use of Atypical Antipsychotic Medications | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/coe1304.html
    April 01, 2013 - In some instances, the review leads to a reconsideration of antipsychotic medication use by the prescriber