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  1. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
    April 22, 2004 - Work System Analysis: The Key to Understanding Health Care Systems 337 Work System Analysis: The Key to Understanding Health Care Systems Ben-Tzion Karsh, Samuel J. Alper Abstract Many articles in the medical literature state that medical errors are the result of systems problems, require systems analyses, a…
  2. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Zierler_81.pdf
    September 01, 2008 - Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety Brenda K. Zierler, PhD; Ann Wittkowsky, PharmD; Gene Peterson, MD, PhD; Jung-Ah Lee, MN; Courtney Jacobson, BA; Robb Glenny, MD; Fred Wolf, PhD; Lynne Robin…
  3. www.ahrq.gov/sites/default/files/2024-04/dykes-report.pdf
    January 01, 2024 - Final Progress Report: Generalizability and Spread of an Evidenced-based Fall Prevention Toolkit: Fall TIPS Project Title: Generalizability and Spread of an Evidenced-based Fall Prevention Toolkit: Fall TIPS (Tailoring Interventions for Patient Safety) Principal Investigator and Team Members. Patricia C. Dykes, An…
  4. www.ahrq.gov/sites/default/files/2024-01/muller-report.pdf
    January 01, 2024 - Final Progress Report: Medication Reconciliation: Bridging Communications Across the Continuum of Care Title: Medication Reconciliation: Bridging Communications Across the Continuum of Care Principal Investigator and Team Members: Melinda Muller, MD, Lynn Belcher, RPh, Melissa Blanchard, MP, Amy Caster-Winegeart, …
  5. www.ahrq.gov/sites/default/files/2024-01/savage-report.pdf
    January 01, 2024 - Final Progress Report: Developing Definitions, Measurement Strategies, and Links to Medication Errors Workarounds: Developing Definitions, Measurement Strategies, and Links to Medication Errors Principal Investigator: Grant T. Savage, PhD (University of Missouri) Team Members: Jonathon R.B. Halbesleben, PhD (U…
  6. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/049-dec-implementation-slides.pptx
    October 01, 2024 - AHRQ Safety Program for MRSA Prevention AHRQ Safety Program for MRSA Prevention Implementation of Chlorhexidine Gluconate (CHG) Bathing and Nasal Decolonization ICU & Non-ICU AHRQ Pub. No. 25-0007 October 2024 AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU AHRQ Safety Program for MRSA Prevention | ICU & No…
  7. www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/ccqmpc/ccqmp-pc-development.pdf
    July 01, 2016 - Care Coordination Quality Measure for Primary Care (CCQM-PC) - Development and Pilot Test of the CCQM-PC Care Coordination Quality Measure for Primary Care (CCQM-PC) Development and Pilot Test of the CCQM-PC v 1.0; Guidance for Use of CCQM-PC v 2.0 Overview of the Care Coordination Quality Measure…
  8. www.ahrq.gov/sites/default/files/publications2/files/takeheart-hybrid-workgroup-evaluation.pdf
    August 01, 2023 - Implementing PCOR To Increase Referral, Enrollment, and Retention in Cardiac Rehabilitation Through Automatic Referral With Care Coordination e Implementing PCOR To Increase Referral, Enrollment, and Retention in Cardiac Rehabilitation through Automatic Referral with Care Coordination Hybrid CR Workgroup Evalu…
  9. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/mod6-care-for-caregiver-guide.pdf
    April 01, 2016 - Purpose: To guide an organization in developing and implementing a Care for the Caregiver program. Who should use this tool? The Care for the Caregiver Program Lead How to use this tool: Use this guide as a checklist to ensure the needed elements for implementation of a Care for the Caregiver program. There are six …
  10. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
    December 01, 2017 - Facilitator Guide: Learning From Defects Through Sensemaking Slide Title and Commentary Slide Number and Slide Learning From Defects Through Sensemaking SAY: This module focuses on the process of Learning From Defects Through Sensemaking. Slide 1 Learning Objectives SAY: At the end of this module, you will …
  11. www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/sample-notification-letters.pdf
    April 07, 2017 - Sample Notification Letters CAHPS Child Hospital Survey CAHPS® Child Hospital Survey and Instructions Sample Notification Letters and Emails for the CAHPS Child Hospital Survey Document No. 961 Updated 4/7/2017 Sample Notification Letters and Emails for the CAHPS® Child Hospital Survey This document cont…
  12. www.ahrq.gov/policymakers/chipra/pubs/background-2012/index.html
    December 01, 2012 - Recommendations to Improve Children's Health Care Quality Measures Background Report on the 2012 Process This background report describes the process used to identify, evaluate, and select children's health care quality measures to be recommended for addition to the initial core set of 24 measures released by…
  13. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/personcentered/qdr2015-chartbook-personcenteredcare.pptx
    September 01, 2016 - Slide 1 National Healthcare Quality and Disparities Report Chartbook on Person- and Family-Centered Care September 2016 This presentation contains notes. Select View, then Notes page to read them. 1 National Healthcare Quality and Disparities Report Annual report to Congress mandated in the Healthcare Research…
  14. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/access/qrdr2015-chartbookaccess.pptx
    January 01, 2020 - Slide 1 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORT Chartbook on Access to Health Care May 2016 1 National Healthcare Quality and Disparities Report Annual report to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129) Provides a comprehensive overview of: Quality of health…
  15. www.ahrq.gov/research/findings/nhqrdr/chartbooks/access/access-slides.html
    June 01, 2018 - Access to Health Care Chartbook: Slide Presentation National Healthcare Quality and Disparities Report Slide 1 National Healthcare Quality and Disparitites Report Chartbook on Access to Health Care May 2016 Slide 2 National Healthcare Quality and Disparities Report Annual report to Congress m…
  16. www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-131-section-5-table-8-9.pdf
    January 01, 2013 - Section 5, Tables 8 and 9 …
  17. www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
    December 01, 2017 - Learning From Defects Through Sensemaking: Facilitator Notes AHRQ Safety Program for Surgery Slide 1: Learning From Defects Through Sensemaking Say: This module focuses on the process of Learning From Defects Through Sensemaking. Slide 2: Learning Objectives Say: At the end of this module, you w…
  18. www.ahrq.gov/hai/cauti-tools/archived-webinars/sustaining-change-transcript.html
    December 01, 2017 - Sustaining Change Webinar Transcript April 14, 2015 Operator: The following is a recording for [Cathy Drury 00:00:02], with the American Hospital Association in Chicago, for the April National Conference 00:00:06 call on Tuesday, April 14, 2015 at 11 a.m. Central Time. Excuse me everyone. We now have all of …
  19. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/sustaining-change-transcript.docx
    April 14, 2015 - April 14, 2015 Sustaining Change Speaker 1: The following is a recording for [Cathy Drury 00:00:02], with the American Hospital Association in Chicago, for the April National conference 00:00:06 call on Tuesday, April 14, 2015 at 11 a.m. central time. Excuse me everyone. We now have all of our speakers in conference. P…
  20. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-refs.html
    August 01, 2023 - Pediatric Diagnostic Safety: State of the Science and Future Directions References Previous Page   Table of Contents Pediatric Diagnostic Safety: State of the Science and Future Directions Introduction Challenges in Approaching Diagnostic Safety Unique to Children Pediatric Diagnostic Safety R…

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