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www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
December 01, 2017 - Try to find out what exactly led to the defect. … Simulate the process that led to the defect. … Ask:
Were these contributing factors that led to or exacerbated the harm? … What led to the next factor that contributed to the defect occurring? … Incompatible blood types could have led to an egregious patient harm.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
December 01, 2017 - Try to find out what exactly led to the defect. … Simulate the process that led to the defect. … ASK:
Were these contributing factors that led to or exacerbated the harm? … What led to the next factor that contributed to the defect occurring? … Incompatible blood types could have led to an egregious patient harm.
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www.ahrq.gov/research/findings/nhqrdr/chartbooks/effectivetreatment/effectivetreatment.html
June 01, 2018 - The reports are produced with the help of an Interagency Work Group led by the Agency for Healthcare … Access to health care has improved dramatically, led by sustained reductions in the number of Americans
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www.ahrq.gov/ncepcr/research-transform-primary-care/transform/profile/hudsonscholle.html
December 01, 2017 - care processes were more comprehensive and efficient after formal transformation activities, which led … that having the authority to make decisions empowered them to be more involved in patient care and led
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www.ahrq.gov/hai/cusp/cauti-interim/cauti-interim2.html
July 01, 2013 - The collaboration is led by the Health Research & Educational Trust (HRET) and its partners, the Michigan … coordination among these projects, the CDC's efforts to reduce HAIs through State health department-led
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www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-additional-topics.html
May 01, 2024 - Health Clinics at High-Risk for Clinician Burnout
P14: Is Telehealth Effective for Providing Nurse-Led … Quality, Safety, Value: Impact of Sudden Shif t to Telehealth Due to COVID-19 Within Nurse-Led Care … care, and home visitation appointments, as a response to the COVID-19 pandemic, on innovative nurse-led
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www.ahrq.gov/cpi/centers/cepi/miller-bio.html
September 01, 2023 - Most recently, Tess was part of the team that led the EvidenceNOW: Advancing Heart Health, AHRQ’s national
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www.ahrq.gov/cpi/about/nac/snac-pancholi.html
December 01, 2021 - In that role, she led the development, maintenance, and dissemination of the AHRQ Quality Indicator measures
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www.ahrq.gov/funding/grantee-profiles/index.html
June 01, 2025 - AHRQ Grantee Profiles
These profiles highlight AHRQ grantees whose work has led to significant … This led me to examine prevention and early intervention resources to promote healthy pregnancies and
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/iowa-case-study.pdf
June 02, 2025 - Other key
factors in success were a well-formed collaborative team led by a
dedicated physician and … Senior IT
engineers and the chief medical informatics officer supported this work and led the Epic template
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-sustainability-centers-of-excellence4.html
April 01, 2025 - This requirement led to collaboration to boost efficiency and quality while the grant was active. … This alignment between the goals of the PI and the goals of CCHMC’s CEO led to some program initiatives
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www.ahrq.gov/news/newsroom/case-studies/ktcquips32.html
October 01, 2014 - The Medical Center also led training for 12 critical-access and three network hospitals in North Dakota
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www.ahrq.gov/news/newsroom/case-studies/ktcquips52.html
October 01, 2014 - The Medical Center also led trainings in 2008 for 94 providers at 24 of the critical access hospitals
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www.ahrq.gov/sops/events/webinars/just-culture.html
December 01, 2018 - the webcast included strategies used to implement Just Culture in a health care system and how these led
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www.ahrq.gov/patient-safety/settings/ambulatory/reduce-readmissions-prim-envscan.html
March 01, 2020 - The project team was led by John Snow, Inc.
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www.ahrq.gov/evidencenow/projects/heart-health/about/stories/in-action/cascades-east.html
March 01, 2021 - This story is courtesy of Healthy Hearts Northwest, the EvidenceNOW Northwest Cooperative , led by the
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www.ahrq.gov/ncepcr/reports/2024-annual-report/background.html
May 01, 2024 - Health Clinics at High-Risk for Clinician Burnout
P14: Is Telehealth Effective for Providing Nurse-Led … AHRQ has led efforts related to primary care transformation, patient-centered medical homes, quality
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www.ahrq.gov/news/newsroom/case-studies/cquips1402.html
January 01, 2014 - That change and others led to a sharp increase—from 59 percent in 2009 to 76 percent in 2011—of employees … Jude's scores on this dimension validated a recent quality improvement project in this area, which led
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/tpc-profile-scholle.pdf
April 01, 2015 - care processes were
more comprehensive and efficient after formal transformation activities, which led … that having
the authority to make decisions empowered
them to be more involved in patient care
and led
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-facguide.docx
January 01, 2017 - Asking the question, “What led to the need to search for and borrow the missing supply or equipment?” … Try to discover what exactly led to the defect. Why were particular decisions made? … Now, ask as many relevant questions as you can think of to discover what led to the defect. … Develop a “system perspective” to see the hidden factors that led to the event. … Was there something about the overall culture or the “people side” that led to the defect?