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www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-nov2022.pdf
March 01, 2023 - Federal Interagency Workgroup--Diagnostic Safety: November Meeting Summary
Federal Interagency Workgroup:
Improving Diagnostic Safety and Quality in Healthcare
November Meeting Summary
Workgroup Goal: Established in response to Senate Report 115-150. The Senate Committee on
Appropriations requested that “AHRQ …
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digital.ahrq.gov/sites/default/files/docs/page/Grannis.ppt
January 01, 2004 - Slide 1
Patient Matching in the Indiana Network for Patient Care
Shaun Grannis, M.D. M.S.
The Regenstrief Institute and
Indiana University School of Medicine
Regenstrief Beginnings
Endowed by Sam Regenstrief - inventor of the low cost dishwasher
Obsessed with process improvement
Supported the creation of the…
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effectivehealthcare.ahrq.gov/sites/default/files/developmental-delays-horizon-scan-high-impact-1412.pdf
December 01, 2014 - #06 Developmental Delays ADHD, and Autism
AHRQ Healthcare Horizon Scanning System – Potential
High-Impact Interventions Report
Priority Area 06: Developmental Delays, ADHD,
and Autism
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaithe…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.158_slideshow.ppt
September 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case September 2007
Medication Reconciliation: Whose Job Is It?
Source and Credits
This presentation is based on the September 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Eric G. Poon, MD, MPH, Ha…
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www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/understand/index.html
June 01, 2020 - Understanding Quality Measurement
Child Health Care Quality Toolbox
The Child Health Toolbox contains concepts, tips, and tools for evaluating the quality of health care for children.
What Is Quality?
The Institute of Medicine defines health care quality as "the degree to which health care services for in…
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psnet.ahrq.gov/node/33745/psn-pdf
February 01, 2013 - Patient Engagement and Patient Safety
February 1, 2013
Weingart SN. Patient Engagement and Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
Perspective
Patient engagement has arrived at the station. A Google search of this phrase identified 335,000 hi…
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psnet.ahrq.gov/node/33763/psn-pdf
March 01, 2014 - How Does Infection Prevention Fit Into a Safety Program?
March 1, 2014
Huang SS. How Does Infection Prevention Fit Into a Safety Program? PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
Perspective
In 1999, the Institute of Medicine (IOM) released the To …
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psnet.ahrq.gov/node/45125/psn-pdf
January 26, 2023 - FDA and ISMP Lists of Look-Alike Drug Names With
Recommended Tall Man Letters.
January 26, 2023
Food and Drug Administration and Institute for Safe Medication Practices. Plymouth Meeting, PA; Institute
for Safe Medication Practices; January 2023.
https://psnet.ahrq.gov/issue/fda-and-ismp-lists-look-alike-drug-name…
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www.ahrq.gov/hai/tools/mvp/about.html
March 01, 2017 - About the Toolkit Development
The toolkit was developed as part of a 3-year project to help staff in intensive care units use Comprehensive Unit-based Safety Program (CUSP) principles to reduce complications from mechanical ventilation, including ventilator-associated pneumonia. It was developed through a partn…
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psnet.ahrq.gov/node/36294/psn-pdf
July 14, 2010 - Care management implementation and patient safety.
July 14, 2010
Alexander JA; Weiner BJ; Baker LC; et al. J Patient Saf. 2006;2(2):83-96.
https://psnet.ahrq.gov/issue/care-management-implementation-and-patient-safety
The Institute of Medicine's Crossing the Quality Chasm report endorsed care management, defined as…
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psnet.ahrq.gov/node/44092/psn-pdf
November 16, 2015 - Does lean management improve patient safety culture?
An extensive evaluation of safety culture in a
radiotherapy institute.
November 16, 2015
Simons P, Houben R, Vlayen A, et al. Does lean management improve patient safety culture? An extensive
evaluation of safety culture in a radiotherapy institute. Eur J Oncol …
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psnet.ahrq.gov/node/44864/psn-pdf
March 23, 2016 - Caught in the middle: a resident perspective on
influences from the learning environment that perpetuate
mistreatment.
March 23, 2016
Bynum WE, Lindeman B. Caught in the Middle: A Resident Perspective on Influences From the Learning
Environment That Perpetuate Mistreatment. Acad Med. 2016;91(3):301-4.
doi:10.1097…
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psnet.ahrq.gov/node/45521/psn-pdf
December 21, 2016 - The effectiveness and risks of long-term opioid therapy
for chronic pain: a systematic review for a National
Institutes of Health Pathways to Prevention Workshop.
December 21, 2016
Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic
pain: a systematic review for…
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psnet.ahrq.gov/node/43710/psn-pdf
October 06, 2016 - Improving medication administration safety: using naïve
observation to assess practice and guide improvements
in process and outcomes.
October 6, 2016
Donaldson N, Aydin C, Fridman M, et al. Improving medication administration safety: using naïve
observation to assess practice and guide improvements in process and…
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psnet.ahrq.gov/node/35643/psn-pdf
June 24, 2010 - Preventing catheter-associated bloodstream infections: a
survey of policies for insertion and care of central venous
catheters from hospitals in the Prevention Epicenter
Program.
June 24, 2010
Warren DK, Yokoe D, Climo MW, et al. Preventing catheter-associated bloodstream infections: a survey of
policies for inse…
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psnet.ahrq.gov/node/40702/psn-pdf
October 16, 2012 - Accountability for medical error: moving beyond blame to
advocacy.
October 16, 2012
Bell SK, Delbanco T, Anderson-Shaw L, et al. Accountability for medical error: moving beyond blame to
advocacy. Chest. 2011;140(2):519-526. doi:10.1378/chest.10-2533.
https://psnet.ahrq.gov/issue/accountability-medical-error-moving…
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psnet.ahrq.gov/node/43550/psn-pdf
October 15, 2014 - Contingency planning for electronic health record–based
care continuity: a survey of recommended practices.
October 15, 2014
Sittig DF, Gonzalez D, Singh H. Contingency planning for electronic health record-based care continuity: a
survey of recommended practices. Int J Med Inform. 2014;83(11):797-804.
doi:10.1016…
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psnet.ahrq.gov/node/35451/psn-pdf
January 05, 2017 - Closing the loop: follow-up and feedback in a patient
safety program.
January 5, 2017
Gandhi TK, Graydon-Baker E, Huber CN, et al. Closing the loop: follow-up and feedback in a patient safety
program. Jt Comm J Qual Patient Saf. 2005;31(11):614-21.
https://psnet.ahrq.gov/issue/closing-loop-follow-and-feedback-pati…
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psnet.ahrq.gov/node/34641/psn-pdf
March 03, 2011 - Study of the deaths associated with anesthesia and
surgery: based on a study of 599, 548 anesthesias in ten
institutions 1948-1952, inclusive.
March 3, 2011
BEECHER HK, TODD DP. A study of the deaths associated with anesthesia and surgery: based on a study
of 599, 548 anesthesias in ten institutions 1948-1952, inc…
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digital.ahrq.gov/sites/default/files/docs/citation/asthmacarewithhit_081011comp.pdf
July 01, 2011 - Pilot and Final Implementation Sites, Project Champions, and Implementation Activities ..... 16
Build Institutional … Build Institutional Support
Dr. … Brottman, Principal Investigator, is building institutional support among the
organizational leadership … Milestones and Timeline
Aspect of Project Milestone/Activity Milestone Completion Date
Build institutional … support –
clinics Pilot site warm-ups* complete May-June 2008
Build institutional support –
clinics