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3021. Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Johnson_90.pdf
      June 10, 2008 - perform an appropriate analysis of the system’s failures or to truly understand systems failures that lead

3022. Guide for Safe Transitions to New Appointments (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/safetransitions/safetrans_guide.pdf
      December 01, 2017 - Pre-Intervention Assessment (PIA) Team Lead Assess current practices in patient and care partner engagement

3023. Final Progress Report: Interactive HIT to promote ambulatory safety among vulnerable diabetes patients (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/sarkar-report.pdf
      January 01, 2024 - disease (e.g., a hypoglycemic episode), whereas potential adverse events were situations that could lead

3024. Final Progress Report: Deployment of Enhanced Critical Imaging Result Notification (DECIRN) (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/lacson2-report.pdf
      January 01, 2025 - It is widely acknowledged that failure to alert ordering physicians with critical test results may lead

3025. High-Performance Work Practices in CLABSI Prevention Interventions (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/clabsi-hpwpreport.pdf
      May 01, 2015 -  Open ICU model ii Conclusions Successful implementation of evidence-based interventions can lead

3026. Final Progress Report: Improving quality of postoperative pain care through innovative use of electronic health records (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/hernandez-boussard-report.pdf
      January 01, 2024 - Inappropriate management of postoperative pain can lead to chronic pain, which significantly and persistently

3027. Patient Safety Data Sharing and Protection from Legal Discovery (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Suydam.pdf
      January 01, 2001 - admissible in court may still be subject to discovery as long as they are “reasonably calculated” to lead

3028. Final Progress Report: Improved Patient Safety with Information Technology (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/overhage-report.pdf
      January 01, 2024 - associated with physician documentation of a billing indication and its associated ICD-9 code might lead

3029. Final Progress Report: Engineering Safe Care Journeys for Vulnerable Older Adults (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/smith-werner-carayon-report.pdf
      January 01, 2025 - rest were inappropriately treated (antibiotic medication error).23 Unnecessary use of antibiotics can lead … We focused on identifying the most critical factors whose changes can lead to the largest reduction … More transfer requests or possible unavailability will lead to longer waiting and handoff time, but

3030. Screening for Family and Intimate Partner Violence: Systematic Evidence Review (pdf file)
      www.ahrq.gov/downloads/pub/prevent/pdfser/famviolser.pdf
      March 01, 2004 - AHRQ is the lead Federal agency charged with supporting research designed to improve the quality of … False-positive tests results, most common in low-risk populations, can lead to inappropriate labeling … Women who have an abuser can become the target of retaliation, which can lead to homicide62. … for perpetrators138-140 would provide needed evidence that identification and intervention can lead

3031. 2018 Hospital Survey on Patient Safety Culture Part I (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/2018hospitalsopsreport.pdf
      March 01, 2018 - promotes patient safety. 72% Organizational Learning 72% of respondents reported that mistakes lead … Who can lead the initiative? 3. What resources will be needed? 4. … It is possible that these different modes could lead to differences in survey responses; further research

3032. 2018 Hospital Survey on Patient Safety Culture Part I (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2018hospitalsopsreport-rev0921.pdf
      March 01, 2018 - patient safety problems 720/o Organizational Learning 72% of respondents reported that mistakes lead … Who can lead the initiative? 3. What resources will be needed? 4. … It is possible that these different modes could lead to differences in survey responses; further research

3033. Primary-Care-Based-Efforts (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/primary-care-based-efforts.pdf
      March 01, 2019 - nationally.68 It described a program in a Minnesota-based health care organization in which nurses take the lead

3034. Primarycareeffortstoreducereadmissions-Envscan (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/PrimaryCareEffortsToReduceReadmissions-envscan.pdf
      March 01, 2020 - nationally.68 It described a program in a Minnesota-based health care organization in which nurses take the lead

3035. Making Healthcare Safer Practices: 14. Delirium (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/delirium-1.pdf
      March 01, 2020 - Intervention is a feasible model for disseminating ACE Unit principles to non- ACE Units and may lead

3036. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Training | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereportguide.html
      September 01, 2017 - This score can indicate the severity of the risk factor and the likeliness that this condition could lead … This score can indicate the severity of the risk factor and the likeliness that this condition could lead

3037. Screening for Thyroid Disease: Systematic Evidence Review (pdf file)
      www.ahrq.gov/downloads/pub/prevent/pdfser/thyrser.pdf
      January 01, 2004 - AHRQ is the lead Federal agency charged with supporting research designed to improve the quality of … major flaw, since differential attention to lipid levels in the treatment and control groups could lead

3038. Pediatric Patient Safety Consortium (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA202-Materials_XIII.pdf
      January 01, 2014 - Experience Co-Chair(s) Marian Earls, MD, FAAP QuIIN Steering Committee Member; helped to lead … Lead on the Minnesota ABCD project; collaborated with MN AAP Chapter; knowledgeable about implementation

3039. Pediatric Patient Safety Consortium (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA205-Materials_XIII.pdf
      August 13, 2014 - Experience Co-Chair(s) Marian Earls, MD, FAAP QuIIN Steering Committee Member; helped to lead … Lead on the Minnesota ABCD project; collaborated with MN AAP Chapter; knowledgeable about implementation

3040. Pediatric Patient Safety Consortium (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA204-Materials_XIII.pdf
      August 25, 2014 - Experience Co-Chair(s) Marian Earls, MD, FAAP QuIIN Steering Committee Member; helped to lead … Lead on the Minnesota ABCD project; collaborated with MN AAP Chapter; knowledgeable about implementation