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1001. The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-issuebrief-maternal-morbidity.pdf
      September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science PATIENT SAFETY e Issue Brief 6 The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science This…

1002. AHRQ Safety Program for Perinatal Care: Shadowing Another Professional Tool (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/professional-tool.docx
      May 01, 2017 - AHRQ Safety Program for Perinatal Care: Shadowing Another Professional Tool AHRQ Safety Program for Perinatal Care Shadowing Another Professional Tool Shadowing Another Professional Tool Problem Statement: Health care delivery is a multidisciplinary practice that requires coordination of care among different profes…

1003. Final Progress Report: Mining complex clinical data for patient safety research (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/hripcsak-report.pdf
      January 01, 2024 - example, use of a keyword search on the electronic record is estimated to have detected .3% to 1.9% of medication … errors.

1004. The Rural Physician Peer Review Model©: A Virtual Solution (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Williams_115.pdf
      June 19, 2008 - The Rural Physician Peer Review Model©: A Virtual Solution The Rural Physician Peer Review Model©: A Virtual Solution Josie R. Williams, MD; Kathy K Mechler, MS, RN, CPHQ; R.B. Akins; John R. Holcomb, MD; Laura K. Gelderd, RN, BSN; R. Kim Clay; Tracy L. Adams; Janine C. Edwards, PhD Abstract Evaluating …

1005. Final Progress Report: Improving Safe Use of Direct Oral Anticoagulants: A Population Health Approach (pdf file)
      www.ahrq.gov/sites/default/files/2024-10/barnes-report.pdf
      January 01, 2024 - Key Words: anticoagulants, clinical decision support, population health, implementation science, medication … error 2 PURPOSE Our primary goal was to improve the safety of DOAC prescribing through the implementation … Prevalence, contributory factors and severity of medication errors associated with direct-acting oral

1006. Assess and Adapt: Understanding the Science of Safety and Reliability | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/assess-adapt-slides.html
      July 01, 2018 - Slide 5 Health Care Defects 7 percent of patients suffer a medication error 2 On average, every

1007. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/painmgmt-facguide.docx
      January 01, 2017 - prevention of such errors as hospital-acquired infections, falls, deep vein thromboses, pressure ulcers, and medication … errors.

1008. Evidence Behind Pain, Agitation, and Delirium: Assessments and Sedation Management: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/technical/pain-mgmt-fac-guide.html
      January 01, 2017 - prevention of such errors as hospital-acquired infections, falls, deep vein thromboses, pressure ulcers, and medication … errors. 

1009. Implement Teamwork and Communication: | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/modules/implement/teamwork-notes.html
      December 01, 2012 - Implement Teamwork and Communication: Facilitator Notes The Implement Teamwork and Communication module of the CUSP Toolkit will help you to identify barriers to communication. Contents Slide 1. Cover Slide Slide 2. Learning Objectives Slide 3. Basic Components and Process of Communication 2 Slide 4…

1010. Learn About CUSP, Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/modules/learn/fac-cusp.html
      December 01, 2012 - Learn About CUSP, Facilitator Notes CUSP Toolkit The Learn about CUSP module of the CUSP Toolkit offers an outline and brief history of the CUSP model, summarizes the CUSP Toolkit modules, and how to use them. Contents Slide 1. Cover Slide Slide 2. Learning Objectives Slide 3. CUSP Supports Kotter's…

1011. AHRQ Safety Program for MRSA Prevention
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/169-cusp-science-safety-slides.pptx
      October 01, 2024 - AHRQ Safety Program for MRSA Prevention AHRQ Safety Program for MRSA Prevention The Science of Safety: Principles in Practice ICU & Non-ICU AHRQ Pub. No. 25-0007 October 2024 AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU The Science of Safety 1 Educational Objectives Describe the patient safety risks tha…

1012. Final Progress Report: Acute Care Learning Laboratory - Reducing Threats to Diagnostic Fidelity in Critical Illness (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/pickering-report.pdf
      January 01, 2025 - Final Progress Report: Acute Care Learning Laboratory - Reducing Threats to Diagnostic Fidelity in Critical Illness Title of Project: Acute Care Learning Laboratory - Reducing Threats to Diagnostic Fidelity in Critical Illness Principal Investigator and Team Members: Principal Investigator: Brian Pickering, MB,…

1013. Care Management: Implications for Medical Practice, Health Policy, and Health Services Research | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/care/coordination/mgmt.html
      August 01, 2018 - For others, medication errors may be decreased.

1014. Approaches to Address Health Risks for Older Adults
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/about/ncepcr-older-adults-presentation.pptx
      March 15, 2025 - Approaches to Address Health Risks for Older Adults National Center for Excellence in Primary Care 1 National Center for Excellence in Primary Care Research Presents Approaches to Address Health Risks for Older Adults January 16, 2025 Presented by: Lisa Kern, MD, MPH Alberta K. Tran, Ph.D., RN, CCRN Yu-J…

1015. Resource List - AHRQ Nursing Home Survey (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursinghome-resourcelist.pdf
      April 01, 2023 - Patient Safety Primer: Medication Errors https://psnet.ahrq.gov/primers/primer/23 A growing evidence … Tool Patient Fall Prevention and Management Protocol With Toileting Program Patient Safety Primer: Medication … Errors Patient Safety Primer: Safety Culture Patient Safety Self-Assessment Tool Person-Centered Care … Patient Safety Primer: Medication Errors 23. Person-Centered Care 24.

1016. Final Progress Report: Quality Improvement and Practice-Based Research in Neurology Using the EMR (pdf file)
      www.ahrq.gov/sites/default/files/2024-04/maraganore-report.pdf
      January 01, 2024 - Final Progress Report: Quality Improvement and Practice-Based Research in Neurology Using the EMR A. Title Page Title of Project: Quality Improvement and Practice-Based Research in Neurology Using the EMR Principal Investigator and Team Members: University of Florida: Demetrius M. Maraganore, MD (principal investi…

1017. Learn About CUSP | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/modules/learn/sl-cusp.html
      December 01, 2012 - Learn About CUSP CUSP Toolkit The Learn about CUSP module of the CUSP Toolkit offers an outline and brief history of the CUSP model, summarizes the CUSP Toolkit modules, and how to use them. Contents Slide 1. Cover Slide Slide 2. Learning Objectives Slide 3. CUSP Supports Kotter's Eight Steps of Cha…

1018. Common Cause Analysis: Focus on Institutional Change (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Browne_5.pdf
      January 20, 2008 - RCA findings to improve patient safety by focusing on one topic at a time, including patient falls, medication … errors, or missing patients.19 Our methodology does not categorize the RCA findings by incident type … For example, a medication error at the point of ordering might be detected at one of many steps, whereas … Michael Cohen on medication error reporting and patient safety.

1019. Situation Monitoring: Severe Hypertension - PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_4-situation-monitoring.pptx
      July 01, 2023 - Situation Monitoring: Severe Hypertension - PowerPoint Presentation Situation Monitoring Severe Hypertension Module 4 of 8 SPPC-II Toolkit AHRQ Pub. No. 23-0046 July 2023 Hospital AIM Team Leads SPPC-II SCRIPT Welcome to Module 4 of the SPPC-II Teamwork Toolkit. In this module, we will talk about situation monito…

1020. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Under the Science of Safety
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-science-safety.pptx
      May 01, 2017 - AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Under the Science of Safety AHRQ Safety Program for Perinatal Care Understand the Science of Safety for Perinatal Safety AHRQ Publication No. 17-0003-4-EF May 2017 1 Learning Objectives 2 AHRQ Safety Program for Perinatal Care Science of S…