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441. Exhibit 7. Interviews by Position in Organization | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit7.html
     November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 7. Interviews by Position in Organization Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Healthcare Case 2. C…

442. Sustainability and the Premortem Tool: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/sustainability/premortem-slides.html
     December 01, 2017 - Sustainability and the Premortem Tool: Slide Presentation AHRQ Safety Program for Surgery Slide 1: AHRQ Safety Program for Surgery—Sustainability Sustainability and the Premortem Tool Slide 2: Learning Objectives After this session, you will be able to– List benefits of a premortem exercise from…

443. Best Practices for Administering SOPS® Surveys Users (Webcast): Introduction (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/best-practices-survey-administration-webcast-intro.pdf
     January 24, 2024 - Best Practices for Administering SOPS® Surveys Users (Webcast): Introduction Best Practices for Administering SOPS® Surveys Webcast January 24, 2024 1:00-2:00 PM ET Webcast Technical Info • Audio issues • Poor Connection • Use Q&A to submit questions • Event Website: https://events.westat.com/sops ► Downlo…

444. Improving Hospital Handoffs Using AHRQ’s Surveys on Patient Safety Culture® Hospital Survey - Introduction (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/01-sops-riverside-handoffs-webcast-intro.pdf
     October 30, 2024 - Improving Hospital Handoffs Using AHRQ’s Surveys on Patient Safety Culture® Hospital Survey - Introduction Improving Hospital Handoffs Using AHRQ’s Surveys on Patient Safety Culture® Hospital Survey Webcast October 30, 2024 1:00-2:00 PM ET Webcast Technical Info • Audio issues • Poor Connection • Use Q&A to s…

445. D. Subcommittee Member and Staff Biographies | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/iomracereport/reldataapd.html
     May 01, 2018 - He also leads an NCI-funded study evaluating randomized interventions to improve systems for colorectal

446. AHRQ Tips for Grant Applicants | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/process/grant-app-basics/apptips.html
     February 01, 2025 - Too little detail in the research plan (leads to reviewers questioning investigators' ability to carry

447. Prologue—Volume 2—Systems Thinking and Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schyve.pdf
     June 02, 2025 - This reconsideration leads to such questions as: What are the human vulnerabilities with respect to

448. Final Progress Report: Proactive Risk Reduction in Medication Prescribing in the Ambulatory Setting (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/field2-report.pdf
     January 01, 2024 - Second, the lack of a reminder system for laboratory appointments frequently leads to missed appointments … Patient on Multiple Meds Leads to Complex Interaction (probability reduced by 25%) • Probability decreases

449. Facilitator Guide: Sustainability and the Premortem (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_premortem_facnotes.docx
     December 01, 2017 - Facilitator Guide: Sustainability and the Premortem Sustainability and the Premortem Tool – Facilitator Notes Slide Title and Commentary Slide Number and Slide Title Slide Sustainability and the Premortem Tool SAY: This module will cover Sustainability and the Premortem Tool. Projects can fail for many reasons,…

450. Antibiotic Stewardship Program Development: Part 2 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/program-part2-facilitator-guide.pdf
     November 01, 2019 - Ideally, ASPs would report on how their work leads to decreased C. difficile infection or CDI rates

451. About AHRQ | Agency for Healthcare Research and Quality
     www.ahrq.gov/cpi/about/index.html
     March 01, 2025 - About AHRQ The Agency for Healthcare Research and Quality (AHRQ) is the federal agency charged with improving the quality and safety of healthcare delivery. The agency develops and disseminates scientific evidence, tools, and data to help patients and their families, healthcare professionals, and policymakers m…

452. Preventing CAUTI in the ICU Setting: Transcript (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-transcript.pdf
     September 01, 2015 - From a public health standpoint, CAUTIs pose another risk, namely that their frequency leads to additional … Slide 5 This leads to another question.

453. Offering Two-Day Training Content | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/situation/teach/two-day.html
     February 01, 2024 - Remind them that situation monitoring is the SKILL that leads to the OUTCOME of situation awareness.

454. Final Progress Report: Improving Transplant Med Safety through a Pharmacist-Led, mHealth-Based Program (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/taber-report.pdf
     January 01, 2024 - This study demonstrated that pharmacist involvement in transitions of care leads to a reduction in

455. Understanding SOPS® Surveys: A Primer for New Users - Intro (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops_101_webcast-2022-intro.pdf
     January 01, 2022 - Understanding SOPS® Surveys: A Primer for New Users - Intro Understanding SOPS® Surveys: A Primer for New Users Webcast November 7, 2022 1:00-2:00 PM ET Need Help? • No sound from computer speakers? ► Choose Phone Call or Call Me • Trouble with your connection or slides not moving? ► Log out and log back …

456. Low Tidal Volume Ventilation: Introduction, Evidence, and Implementation: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-intro-fac-guide.html
     February 01, 2017 - This leads to stiff lungs, and can lead to overinflation and underinflation in air distribution across … It also leads to inflammatory changes, additional tissue injury, and more stiffness.

457. Guidance for Teaching Section 4: Implementation | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/implement/pre-teach.html
     May 01, 2023 - Guidance for Teaching Section 4: Implementation Who Should Teach and Learn These Topics Only instructors with substantial experience teaching and implementing TeamSTEPPS across an organization or units should use the material in section 4: Implementation. Ideally, multiple trainers should lead trainings discu…

458. Diagnostic Failure: A Cognitive and Affective Approach (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
     January 01, 2004 - The summation of their effects leads to at least one, but more often an aggregate of cognitive dispositions … fast and frugal approach to his complaint involves primarily a pattern recognition heuristic that leads

459. Prologue: Laying the Foundation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Prologue_Henriksen_Vol1.pdf
     June 02, 2025 - Prologue: Laying the Foundation Prologue Laying the Foundation Kerm Henriksen, PhD The volume starts with papers that look to the future and examine the past with respect to patient safety; however, its overarching theme is assessment. An underlying premise to any volume that focuses on assessment is tha…

460. 130-Ss-Swiss-Cheese-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
     April 01, 2025 - Active failures occur when an “operator” performs an unsafe action that leads to an event.