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  1. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Baker_107.pdf
    March 30, 2008 - Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems Donald K. Baker, PharmD; James M. Hoffman, PharmD; Gregory A. Hal…
  2. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/reducing-adverse-drug-1.pdf
    March 01, 2020 - Making Healthcare Safer Practices: 9. Reducing Adverse Drug Events in Older Adults Reducing Adverse Drug Events in Older Adults 9-1 9. Reducing Adverse Drug Events in Older Adults Authors: Tara R. Earl, Ph.D., M.S.W., Nicole D. Katapodis, M.P.H., and Stephanie R. Schneiderman, M.P.P. Reviewers: Scott Winiecki, M.D…
  3. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/prev-handouts.html
    December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Facilitator Training—Handouts: Pressure Ulcer Prevention Implementation   Implementation of the Prevention Reports Into Day-to-Day Practice Review of the Nursing Home's Pressure Ulcer Prevention Implementation Scripted Exercise #…
  4. www.ahrq.gov/sites/default/files/publications/files/ltcmodule1.pdf
    June 01, 2012 - Improving Patient Safety in Long-Term Care Facilities, Module 1 Improving Patient Safety in Long-Term Care Facilities Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov Module 1. Detecting Change in a Resident’s Condition Student Workbook These training materi…
  5. www.ahrq.gov/prevention/guidelines/tobacco/clinicians/references/meta/meta02.html
    October 01, 2014 - Studies in Meta-analyses (continued, 2) This Clinical Practice Guideline used the references below in meta-analyses of research on treating tobacco use and dependence. Table 6.13. Meta-analysis (2000): Effectiveness of and estimated abstinence rates for various types of format (n = 58 studies) Barbarin OA. …
  6. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Devine_83.pdf
    April 06, 2008 - Implementing an Ambulatory e-Prescribing System: Strategies Employed and Lessons Learned to Minimize Unintended Consequences Implementing an Ambulatory e-Prescribing System: Strategies Employed and Lessons Learned to Minimize Unintended Consequences Emily B. Devine, PharmD, MBA; Jennifer L. Wilson-Norton, RPh, MBA…
  7. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/047-evidence-behind-decolonization-strategies-notes.docx
    October 01, 2024 - AHRQ Safety Program for MRSA Prevention The Evidence Behind Decolonization Strategies for MRSA ICU & Non-ICU Slide Title and Commentary Slide Number and Slide Evidence Behind Decolonization Strategies for MRSA SAY: Welcome to this presentation on the current evidence behind decolonization strategies as part of an …
  8. www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/after-demonstration.pdf
    June 02, 2025 - After The Demonstration: What States Sustained After the End of Federal Grants to Improve Children’s Health Care Quality Vol.:(0123456789)1 3 OavgtpffnEjkndffnHganvjffnLffn FQKffn3203229/s32;;5/239/25;3/z ’ ’ K ’ ’ ’ AhverfkThefkDemqpuvraviqp:fkWhavfkSvaveufkSuuvaipeffkAhverfkvhefjGpffk qhfjHeferanfkGrapvufkv…
  9. www.ahrq.gov/sites/default/files/publications2/files/distributed-cognition-er-nurses_0.pdf
    August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Issue Brief 8 Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department PATIENT SAFETY e This page intentionally left blank. e Issue Brief 8 Distributed Cognition and the Rol…
  10. www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-207-section-2-tables-1-5.pdf
    June 02, 2025 - CHIPRA 207: Section 2, Tables 1-5 Section II. Detailed Measure Specifications Table 1: Exclusion Criteria- ICD-9 Codes for Congenital Anomalies Congenital Anomaly Group ICD-9 Codes Cardio 746.6, 746.7, 746.81, 746.82, 746.83, 746.84, 746.85, 746.8…
  11. References (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/subglottic-litreview.docx
    January 01, 2017 - References Summary Continuous or frequent intermittent suctioning of subglottic secretions, via an endotracheal tube (ETT) specially designed with a dorsal lumen to accommodate this, is associated with up to a 50 percent decreased incidence of aspiration and ventilator-associated pneumonia (VAP). Guidelines support …
  12. www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/60-tenn-health-coach-sustainability-plan-toolkit.pdf
    June 02, 2025 - Health Coach Intervention Sustainability Plan Health Coach Intervention Sustainability Plan Medicare Preventative Services i. In Office Visits, Modifiers and Add-On Codes a. Annual Wellness Visits 1. Medicare i. Description-Initial Preventative Physical Exam (IPPE) also known as “Welcome to Medicare” visit ii. …
  13. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
    January 01, 2003 - Do Transient Working Conditions Trigger Medical Errors? 53 Do Transient Working Conditions Trigger Medical Errors? Deborah Grayson, Stuart Boxerman, Patricia Potter, Laurie Wolf, Clay Dunagan, Gary Sorock, Bradley Evanoff Abstract Objective: Organizational factors affecting working conditions for health …
  14. www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
    August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Issue Brief 8 Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department PATIENT SAFETY e This page intentionally left blank. e Issue Brief 8 Distributed Cognition and the Rol…
  15. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
    January 01, 2004 - Creating a Culture of Patient Safety through Innovative Hospital Design 425 Creating a Culture of Patient Safety through Innovative Hospital Design John G. Reiling Abstract When SynergyHealth, St. Joseph’s Hospital of West Bend, Wisconsin, decided to relocate and build an 82-bed acute care facility, we reco…
  16. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
    June 30, 2004 - Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative 133 Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative Daniel M. Harris, John M. Westfall, Douglas H. Fernald, Christine W. Duclos, David R. West, Linda Niebauer, Linda Ma…
  17. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Carayon.pdf
    January 01, 2004 - Observing Nurse Interaction with Infusion Pump Technologies 349 Observing Nurse Interaction with Infusion Pump Technologies Pascale Carayon, Tosha B. Wetterneck, Ann Schoofs Hundt, Mustafa Ozkaynak, Prashant Ram, Joshua DeSilvey, Brian Hicks, Tanita L. Robert, Myra Enloe, Rupa Sheth, Sade Sobande Abstract…
  18. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Kravitz.pdf
    February 09, 2005 - From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator 395 From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator Richard L. Kravitz, Jonathan D. Neufeld, Michael A. Hogarth, Debora A. Paterniti, William Dager, …
  19. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Wideman.pdf
    April 20, 2004 - Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation 437 Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation Mary V. Wideman, Michael E. Whittler, Timothy M. Anderson Abstract An electronic barcode medication administration sy…
  20. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
    March 01, 2004 - Standardizing Medication Error Event Reporting in the U.S. Department of Defense 361 Standardizing Medication Error Event Reporting in the U.S. Department of Defense Ronald A. Nosek, Jr., Judy McMeekin, Geoffrey W. Rake Abstract Soon after the 1999 Institute of Medicine report, To Err Is Human, was released, …

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