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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-system-focused-event-guide.pdf
April 01, 2016 - The standard solution is to blame the people involved. … This is especially important for individuals who were directly involved
in the event. … Technology involved (e.g., any usability issues, downtime, individual knowledge gaps)
3. … ■ Were any of the involved individuals
working extended shifts (longer than 12
hours)? … Disciplinary: actions taken toward involved staff members.
AHRQ Pub.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
March 01, 2004 - in the error,” “error result on patient
care,” and “medical devices involved in the error.” … Of the actual events, 26
percent involved female patients, 22 percent involved male patients, and 52 … percent involved patients whose gender was not indicated by the individual who
made the report. … in medication errors
An analysis of drug products involved in inpatient medication error reports … Ranked top 10 inpatient products involved in errors that reached the patient,
Table 4.
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www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/surgical-roles.html
December 01, 2017 - How To Use This Tool
Evaluate the amount of work involved for each task. … Evaluate the type of work involved for each anticipated task.
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www.ahrq.gov/cahps/cahps-database/child-hcahps-database/participate.html
March 01, 2025 - This page explains the requirements and the steps involved in participating.
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www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamilyex11.html
July 01, 2018 - Web Sites Reviewed
Appendix D: Data Abstraction Protocol
Description
Who is involved
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses1.html
August 01, 2022 - distributed cognition, 8 this view of the diagnostic process is especially salient because various involved … Since no single individual can grasp everything, 9 distributed cognition allows involved parties to
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www.ahrq.gov/hai/cusp/toolkit/shadowing.html
December 01, 2012 - All staff involved in the delivery of patient care in units with poor Safety Attitude Questionnaire scores … What happened during the shadowing exercise that involved multiple practice domains? … Did the providers involved seek help from a supervisor?
6.
-
www.ahrq.gov/research/findings/nhqrdr/chartbooks/personcentered/measures4.html
June 01, 2018 - 4 or more chronic conditions were significantly less likely than those with 0 or 1 condition to be involved … from 2002 to 2013, among people with a usual source of care, Blacks were more likely than Whites to be involved … 2002 to 2013, among people with a usual source of care, Hispanics were more likely than Whites to be involved
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-141-section-2-tech-specs.pdf
December 01, 2012 - can be considered chronic, malignant, or progressive,
and whether multiple body systems are involved … To assign involved body system(s) and progressive status, Seattle Children's Research Institute … multiple lines (or single line) of individual claims for a person,
identifying body systems involved … one or more conditions are malignant
'Non-complex Chronic': 1) only one body system is involved … one or more conditions are malignant
'Non-complex Chronic': 1) only one body system is involved
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/surgical_roles.docx
December 01, 2017 - How To Use This Tool
Evaluate the amount of work involved for each task. … Evaluate the type of work involved for each anticipated task.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/learn_from_defects.docx
December 01, 2017 - All staff involved in the care system that produced a defect should be present when that defect is evaluated … For this investigation, put yourself in the place of those involved – and in the middle of the event … Ask frontline staff involved in the defect whether the interventions improved care. … For this investigation, put yourself in the place of those involved – and in the middle of the event … Ask frontline staff involved in the defect whether the interventions improved care.
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-3-implementation-guide.pdf
June 02, 2025 - o Gather all relevant stakeholders, including past patients and those involved in data
collection and … Staff who are involved feel heard and have a greater
chance of buying in and adopting new workflows … Those
involved in the mapping process should “observe” the process, as much as possible, prior to coming … Include those involved in the cardiac rehabilitation referral process.
c. … Send around for to people in various departments involved in the cardiac rehabilitation process
and
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www.ahrq.gov/pqmp/implementation-qi/toolkit/asthma/key-drivers.html
July 01, 2021 - that impact the measure, as well as two initiative-specific KDDs that demonstrate the specific drivers involved … Although each initiative involved a different set of QI strategies, the global aim of each was to test
-
www.ahrq.gov/cahps/surveys-guidance/helpful-resources/planning/Develop-an-Evaluation-Plan.html
December 01, 2019 - after the survey results are released, conduct focus groups or formal debriefings with all who were involved … implementation (if you can afford it, it may be helpful to hire a professional facilitator who was not involved
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_508.docx
January 01, 2010 - Who: Hospital to identify staff to be involved in meeting, for example the nurse, doctor, patient advocate … Patient identifies if family or friends need to be involved.
Offer to make followup appointments. … clinician goals
Explained medications to patient and family
Morning
Noon
Evening
Bedtime
Other
Involved … clinician goals
Explained medications to patient and family
Morning
Noon
Evening
Bedtime
Other
Involved … clinician goals
Explained medications to patient and family
Morning
Noon
Evening
Bedtime
Other
Involved
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_508.pdf
January 01, 2010 - Who: Hospital to identify staff to be involved in
meeting, for example the nurse, doctor, patient
advocate … Patient identifies if family or friends need to be
involved. … goals
Explained medications to
patient and family
Morning
Noon
Evening
Bedtime
Other
Involved … goals
Explained medications to
patient and family
Morning
Noon
Evening
Bedtime
Other
Involved … goals
Explained medications to
patient and family
Morning
Noon
Evening
Bedtime
Other
Involved
-
www.ahrq.gov/news/psnet.html
March 01, 2025 - patient safety, features a new set of articles including: Ambulatory medication errors and adverse events involved
-
www.ahrq.gov/hai/clabsi-tools/appendix-7.html
March 01, 2018 - If no, explain:
1
Patient's location/room number(s)
2
Did all personnel involved … 17
Can each staff member involved in this patient's care verbalize correct strategies to prevent CLABSI
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/professional-tool.docx
May 01, 2017 - Who should use this tool:
All staff involved in the delivery of patient care in units with poor Safety … What happened during the shadowing exercise that involved multiple practice domains? … Did the clinicians involved seek help from a supervisor or peer?
6.
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/healthit-ed-1.html
February 01, 2021 - diagnostic decision making. 1 Patient engagement refers to the concept of patients being actively involved