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3541. Study Reveals Sharp Decline in Mothers’ Mental Health | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsletters/e-newsletter/960.html
      June 01, 2025 - Study Reveals Sharp Decline in Mothers’ Mental Health Issue Number 960 AHRQ News Now is a weekly newsletter that highlights agency research and program activities. June 3, 2025 AHRQ Stats: U.S. Adults Treated for Diet-Related Conditions  An average of 84.1 million adults were treated for at least one ma…

3542. Supporting Clinical Staff Who Prescribe Opioids to Older Adults: Providing Targeted Educational Sessions to Meet Needs Case Study (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-case-study-prescribe-opioids.pdf
      June 02, 2025 - Supporting Clinical Staff Who Prescribe Opioids to Older Adults: Providing Targeted Educational Sessions to Meet Needs Case Study Focus on High Leverage Change: Opioi…

3543. Equal Employment Opportunity Data Posted Pursuant to the No Fear Act: AHRQ for 4th Quarter 2022 for period ending September 30, 2022 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policy/eeo/nofear-ahrq-fy2022-4thq.pdf
      September 30, 2022 - Equal Employment Opportunity Data Posted Pursuant to the No Fear Act: AHRQ for 4th Quarter 2022 for period ending September 30, 2022 This report was generated with a future date. Therefore, the quarter numbers may be incomplete Equal Employment Opportunity Data Posted Pursuant to the No Fear Act: AHR…

3544. Final Progress Report: Ultrasound by Emergency Physicians in Ectopic Pregnancy (pdf file)
      www.ahrq.gov/sites/default/files/2025-05/stein-report.pdf
      January 01, 2025 - Final Progress Report: Ultrasound by Emergency Physicians in Ectopic Pregnancy Ultrasound by Emergency Physicians in Ectopic Pregnancy Principal Investigator: John C. Stein, MD, MAS Team Members: Ralph Gonzales, MD, MPH (Primary Mentor) Michael Callaham (Co-Mentor) Roy Filly (Co-Mentor) Organization: Uni…

3545. September: A Month for Increasing Awareness About Sepsis | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsletters/e-newsletter/973.html
      September 01, 2025 - September: A Month for Increasing Awareness About Sepsis Issue Number 973 AHRQ News Now is a weekly newsletter that highlights agency research and program activities. September 3, 2025 Today’s Headlines: September: A Month for Increasing Awareness About Sepsis . Opportunities for Diagnosis and Treatment…

3546. Understand the Science of Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/modules/understand/science-safety-slides.html
      July 01, 2018 - Understand the Science of Safety Presentation Slides The Understand the Science of Safety module of the CUSP Toolkit discusses the importance of understanding system design, safe design principles, and valuing diverse input from team members. By analyzing patient safety as a science, frontline providers will …

3547. Endnotes | Agency for Healthcare Research and Quality
      www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/implementation-guides/implementation-guide2/implguide2ref.html
      September 01, 2014 - Designing Care Management Entities for Youth with Complex Behavioral Health Needs Endnotes Previous Page Next Page Table of Contents Designing Care Management Entities for Youth with Complex Behavioral Health Needs Part 1: An Introduction to Care Management Entities (CMEs) Part 2: Assessing Stat…

3548. Recommendations and Areas for Future Research | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses4.html
      August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Recommendations and Areas for Future Research Previous Page Next Page Table of Contents Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Introduction The The…

3549. Resources by National Action Plan Foundational Area | Agency for Healthcare Research and Quality
      www.ahrq.gov/action-alliance/resources/foundational-area.html
      March 01, 2025 - Resources by National Action Plan Foundational Area Contents Culture, Leadership, and Governance Patient and Family Engagement Workforce Safety Learning Systems Culture, Leadership, and Governance AHRQ Patient Safety Net (PSNet) Primer: Safety Culture This resource provides an overview of patient safety culture…

3550. Background Report for the Request for Public Comment on Initial, Recommended Core Set of Children's Healthcare Quality Measures for Voluntary Use by Medicaid and CHIP Programs | Agency for Healthcare Research and Quality
      www.ahrq.gov/policymakers/chipra/overview/background/next-steps2.html
      December 01, 2009 - immunizations and early identification of problems, and they provide opportunities to discuss developmental issues

3551. Improving Patient Safety with the Military Electronic Health Record (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Charles.pdf
      January 24, 2004 - access a patient’s prescription history using CHCS to better identify and prevent drug interaction issues … The system automatically issues distinct displays of test results or abnormalities to providers. … Order entry in a computer-based system eliminates legibility issues, while reducing duplication of … , and assess productivity and workflow issues. … The Deployment Operations Center further ensures prompt resolution of implementation issues and directs

3552. Making a Case for Organizational Change in Patient Safety Initiatives (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Ramanujam.pdf
      January 01, 2003 - This paper discusses critical issues in effective change management, drawing attention to the unintended … It includes pointers from organizational change literature on critical issues in managing change, such … authors’ observations of 40 hospitals in southwestern Pennsylvania, to highlight change management issues … Patient safety through the looking glass of organizational change To discuss the organizational issues … Often this group has insufficient authority to tackle issues that cut across departmental boundaries

3553. Department of Veterans Affairs Emergency Airway Management Initiative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Stalhandske_71.pdf
      February 23, 2008 - As a result of root cause analyses on issues encountered in airway management responses, the VA gathered … VA national policy, how it was implemented, support from national societies’ position papers, and issues … The Department of Veterans Affairs addressed these issues by rolling out a national initiative requiring … Thus, a nursing home facility without acute care issues might meet that standard by having personnel … We felt there were three key issues to consider in terms of who should be trained: 4 1.

3554. Appendix A. Checklists for Assessing Executive and Physician Champion Potential | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/impl-guide/implementation-guide-appendix-a.html
      October 01, 2015 - . __ Stays current on issues in patient safety, quality improvement, and risk-management through variety … administration. __ Easy to talk to or deal with, welcomes contact by others, makes time to attend to their issues … creating a mutual understanding of the needs of all parties, and facilitating a win-win solution to issues … others. __ Easy to talk to or deal with, welcomes contact by others, makes time to attend to their issues

3555. Module 1- Component Kit (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/overview/component-kit.docx
      May 01, 2017 - a scan of cases scheduled for the current day to anticipate any special needs or anticipated safety issues … fall into four rough groupings: (1) conformance with established protocols and procedures; (2) simple issues … that have an obvious “just fix it” solution; (3) issues that are symptomatic of a problem that is not … “Symptomatic” issues typically lead to a root cause analysis followed by small-scale testing of solutions

3556. AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/timeline.html
      December 01, 2014 - The facilitator helps with implementation issues. … facilitator will help the team during the next 3 months to train staff and to problem solve implementation issues … months, the facilitator’s role is to check in to identify obstacles that could occur and to troubleshoot issues … as needed, such as turnover of key staff, computer glitches, and implementation issues.

3557. Guide to Sustaining a Program To Reduce Catheter-Associated Urinary Tract Infections in Long-Term Care | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/sustainability/guide.html
      March 01, 2017 - team, focuses on the input of frontline staff, discusses the importance of a common goal, identifies issues … It builds the capacity to address safety issues by combining clinical best practices and the science … , it can provide data transparency throughout the facility and opportunities to troubleshoot if any issues … Assess what is currently working by reviewing cases of resident safety issues (e.g., CAUTI) each month

3558. Implementation-Guide-Appendix-A (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-a.docx
      January 01, 2008 - results · Spoken of in a positive, respectful manner by medical and hospital staff · Stays current on issues … administration · Easy to talk to or deal with, welcomes contact by others, makes time to attend to their issues … creating a mutual understanding of the needs of all parties, and facilitating a win-win solution to issues … for others · Easy to talk to or deal with, welcomes contact by others, makes time to attend to their issues

3559. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module7/module7-resolution-facilitator.pptx
      August 24, 2015 - CANDOR Resolution: The actions associated with addressing the needs or issues of patients, families, … overall process can lead to a financial settlement, but might not always lead to resolution of all issues … important to recognize the importance of disclosure and resolution in addressing unresolved needs or issues … The malpractice climate is different in each State, so organizations should be knowledgeable of the issues

3560. Project Report - Lean Sigma (ppt file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/framework-slides/CUSP-A-Framework-for-Success-Mar-7-2012-508.ppt
      January 01, 2012 - senior executive regularly attends safety meetings on my unit, and can identify the top three safety issues … safety team is currently working on: Very rarely attends and is out of touch with our unit safety issues … Intermittently attends, and is somewhat aware of our unit safety issues Attends whenever possible, … and is aware of our unit’s top three safety issues   3) By ensuring that your senior executive is