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ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/modules/implementation/audit-briefing-slides.html
December 01, 2017 - POSTOP
Nurse-led handoff communication.
Include procedure, medications, etc. … POSTOP
Nurse-led handoff communication.
Include procedure, medications, etc.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/48-prep-colorectal-facilitator.docx
June 01, 2023 - This led to a seriously flawed study in England by a prominent colorectal surgeon who compared an effective
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medical-office-ve-suppl-item-set-english-2023.docx
January 01, 2023 - Patient and family member preferences have led to changes in our workflow
1
2
3
4
5
9
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
June 01, 2021 - 17
Changing the System
17
Review
Consider system/active failures which may have led to the problem
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ce.effectivehealthcare.ahrq.gov/gam/summaries/domain-definitions/index.html
July 01, 2018 - Process measures are supported by evidence that the clinical process—that is the focus of the measure—has led … Population process measures are supported by evidence that the process—that is the focus of the measure—has led
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/evidencenow/projects/urinary/evidencenow_optima.pdf
January 01, 2024 - Academic detailing entails group lectures led by a champion specialist/primary
care provider (PCP) dyad
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state-apc.html
January 01, 2024 - The initial rapid narrative review led us to 10 domains of diagnostic safety [read through list].
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ce.effectivehealthcare.ahrq.gov/news/blog/ahrqviews/financial-strains-healthcare.html
November 01, 2023 - September that it is beginning rulemaking to remove medical bills from credit reports that have often led
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ce.effectivehealthcare.ahrq.gov/patient-safety/news-events/psaw-2024/index.html
March 01, 2024 - offering virtual and limited in-person TeamSTEPPS 3.0 and TeamSTEPPS Diagnosis Improvement trainings led
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cpi/about/profile/ahrq-profile16.pdf
May 01, 2016 - In the intervening years,
AHRQ has led the Nation in responding to those issues
and improving the safety
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-slides.pptx
January 01, 2017 - What systems may have led to these events?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/candor-acknowledgments.pdf
September 14, 2017 - - Anna Wojcik, M.P.H
Expert Faculty led the design and teaching of the CANDOR curriculum, guided
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/tpc-profile-gabbay.pdf
April 01, 2015 - varied in size from 2
to 25 providers; one quarter of the
Federally Qualified Health Centers
were led
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/childhealth/usingthecoresetofqm.pdf
February 01, 2010 - When it was enacted in 2009, CHIPRA set in motion a series of initiatives that have led to a vigorous
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/index.html
July 01, 2023 - AIM, an ongoing effort led by the U.S.
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ce.effectivehealthcare.ahrq.gov/news/blog/ahrqviews/digital-healthcare-research-program.html
September 01, 2023 - In 2022, DHR managed a significant body of research: 108 grants and seven research contracts led by researchers
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_training.pptx
December 01, 2017 - efforts can be successful.
3
Advances in Medicine: Lingering Contradictions
Advances in medicine have led … What systems may have led to these events? … What systems may have led to the events?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight02.pdf
September 08, 2015 - quality
of care for children and adults, but varying conceptual definitions
and measurement goals have led … measurement across
the demonstration sites, and lack of
measurement in some comparison
practices, led … This led
to the creation of the Medical Home
Index-Revised Short Form (MHI-RSF).9
The MHI-RSF consists
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Campbell_94.pdf
March 30, 2008 - In addition, informal sharing of patient
stories at Safety Mentor meetings ultimately led to a system-wide … In 2005, the work of one safety team led to significant
changes in the electronic event reporting system … As mentioned earlier, this insight led to development of a system-wide storytelling forum called
“No
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops-items-composites.pdf
February 16, 2021 - Mistakes have led to positive changes here.
A13.