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  1. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/sppcii-hypertension-scenarios.pptx
    July 01, 2023 - Smith’s severe-range blood pressure, explaining that the difficulty in obtaining IV access led to a delay … Smith had dangerously elevated blood pressure, which could have led to stroke or seizures.
  2. Slide 1 (ppt file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/connecting-dots-100813.ppt
    January 01, 2013 - Mistakes have led to positive changes here. (A9) 3. … Mistakes have led to positive changes here. (A9) 63% 3.
  3. www.ahrq.gov/hai/cauti-tools/archived-webinars/assess-adapt-transcript.html
    December 01, 2017 - further, we wonder how can this be when we can see that there have been advances in medicine that have led … of the NASA and its engineers and other employees to fix the problem with o-rings that we now know led
  4. Paul Tedrick (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/assess-adapt-transcript.doc
    June 03, 2014 - further, we wonder how can this be when we can see that there have been advances in medicine that have led … of the NASA and its engineers and other employees to fix the problem with o-rings that we now know led
  5. www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-8.html
    July 01, 2019 - General huddle includes entire team; specific huddle is provider-led. … The entire core team meets for a brief huddle at 8 a.m. led by the nursing supervisor to optimize clinic
  6. www.ahrq.gov/hai/cauti-tools/archived-webinars/preventing-cauti-plan-b-transcript.html
    December 01, 2017 - the national data is that the intervention on the floor, both in the medical and surgical side, have led … That led us to think that if we actually asked some key MDs on the floor to take the GPS that could allow
  7. Rafael Borja (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-plan-b-transcript.doc
    November 04, 2014 - the national data is that the intervention on the floor, both in the medical and surgical side, have led … That led us to think that if we actually asked some key MDs on the floor to take the GPS that could allow
  8. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-nhqdr-es-rev.pdf
    January 01, 2023 - These surges led to recurring spikes in cases, hospitalizations, and deaths throughout 2021. … required that nursing home workers isolate several days to weeks to avoid infecting residents, which led
  9. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/OConnor.pdf
    January 01, 2003 - clinical trial we are currently participating in, paper-based clinical decision support tools have led … LDL, or SBP in certain groups of patients, such as those with diabetes or heart disease, has often led
  10. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/sepsis-1.pdf
    March 01, 2020 - contribute to the high mortality rate for sepsis.9 The need for early recognition and rapid treatment have led … level due to the risk of fluid overload.12 The need to diagnose sepsis unambiguously and quickly has led … colleagues found that a nurse-administered screening tool in the ED of a 320-bed community hospital led … screening result (positive or negative), which suggests that a positive screening test may have led … Paper-based, nurse-led screening tools appear to be more sensitive in the identification of septic
  11. www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/2018hospitalsopsreport_0.pdf
    March 01, 2018 - Organizational learning—Continuous improvement Mistakes have led to positive changes and changes are … (A6) 84% Mistakes have led to positive changes here. … doing things to improve patient safety. 84% 6.51% 40% 75% 80% 84% 88% 91% 100% A9 Mistakes have led … Mistakes have led to positive changes here. 64% 64% 0% 18% -41% 4% -5% A13 3.
  12. www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2018hospitalsopsreport-rev0921.pdf
    March 01, 2018 - Organizational learning—Continuous improvement Mistakes have led to positive changes and changes are … (A6) 84% Mistakes have led to positive changes here. … doing things to improve patient safety. 84% 6.51% 40% 75% 80% 84% 88% 91% 100% A9 Mistakes have led … Mistakes have led to positive changes here. 64% 64% 0% 18% -41% 4% -5% A13 3.
  13. www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/2018hospitalsopsreport.pdf
    March 01, 2018 - Organizational learning—Continuous improvement Mistakes have led to positive changes and changes are … (A6) 84% Mistakes have led to positive changes here. … doing things to improve patient safety. 84% 6.51% 40% 75% 80% 84% 88% 91% 100% A9 Mistakes have led … Mistakes have led to positive changes here. 64% 64% 0% 18% -41% 4% -5% A13 3.
  14. www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case1.html
    November 01, 2014 - Frontline staff reported that these efficiency gains led to increased physician productivity and patient … year after completing this Patient Flow project, an unfavorable shift in patient satisfaction scores led … commented that the cultural transformation initiative and the shared mission to produce results has also led … A more hierarchically controlled, and expert-led approach to Lean may improve success.
  15. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/ced-topic-refinement.pdf
    November 01, 2022 - Only 4 of these CEDs led to a NCD for continued coverage, and 2 CEDs led to coverage revocation and … Perceived need to reflect best practices for understanding heterogeneity in treatment effectiveness ledLed by the guiding questions, we then addressed the key questions that were posed by AHRQ on behalf
  16. www.ahrq.gov/hai/tools/perinatal-care/modules/strategies/medication/tool-safe-mgso4.html
    November 01, 2018 - Use unit-established approach for nursing-led patient education regarding magnesium sulfate infusion,
  17. www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/dx-journey-mr-kane.pptx
    June 14, 2016 - The story outlines several areas where communication failures led to missed and delayed diagnosis that
  18. www.ahrq.gov/research/findings/studies/index.html?page=160
    January 01, 2024 - This led to high-priced HOPDs being less likely to be chosen by CalPERS patients for both procedures.
  19. www.ahrq.gov/research/findings/studies/index.html?page=417
    January 01, 2024 - Also, interventions in communication or workflow led to greater improvements in clinician satisfaction
  20. www.ahrq.gov/research/findings/studies/index.html?page=240
    January 01, 2024 - substantial gaps existed in processes for diagnosis and referral of patients with hyperparathyroidism that led

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