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3001. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/overview-cuspmvp-facguide.docx
      January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle Slide Title and Commentary Slide Number and Slide Title Slide Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients SAY: Today, we will be giving you an overview of the Comprehensive Unit-based Safety Program…

3002. The Different Count Contributions to Retention (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
      January 01, 2024 - The Different Count Contributions to Retention Differential Count Contributions in Retained Surgical Sponge Cases: Examination of Administrative Penalty Cases from the California Department of Public Health (CDPH), Health and Safety Code Section 1280.1 Enforcement Reports from 2007-2014 A NoThing Left Behin…

3003. Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax | PSNet
      psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
      December 14, 2022 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax Citation Text: Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …

3004. Complications of Vascular Access Procedures in Patients with Kidney Disease | PSNet
      psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
      November 15, 2023 - Complications of Vascular Access Procedures in Patients with Kidney Disease Citation Text: Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

3005. Final Progress Report: Using Performance Measurement To Improve the Quality and Safety of Healthcare (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/ballard-report.pdf
      January 01, 2024 - Final Progress Report: Using Performance Measurement To Improve the Quality and Safety of Healthcare Element 1. Title Page: Using Performance Measurement to Improve the Quality and Safety of Healthcare Report on The International Society for Quality in Health Care (ISQua) 6th International Summit on Indic…

3006. Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/cusp/overview-cusp-mvp-facguide.html
      February 01, 2017 - Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients: Facilitator Guide AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients Say: …

3007. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865656/psn-pdf
      April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous Combination April 24, 2024 Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination The Case A 26-ye…

3008. The History of Patient Roles | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patient-role2.html
      September 01, 2024 - The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception Toward Co-Design The History of Patient Roles Previous Page Next Page Table of Contents The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception Toward Co-Design Introduction The History of Pat…

3009. References | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patient-role-references.html
      September 01, 2024 - The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception Toward Co-Design References Previous Page   Table of Contents The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception Toward Co-Design Introduction The History of Patient Roles Impact of Dis…

3010. Patient Safety Tools | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
      June 01, 2022 - Patient Safety Tools The Agency for Healthcare Research and Quality (AHRQ) offers tools for health care organizations, providers, policymakers, and patients to improve patient safety in health care settings. The free tools and resources listed here are available online and in print. Contents   Tools for H…

3011. WITHIN 3 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/shah.pdf
      May 29, 2025 - WITHIN 3 INNOVATIONS CONFERENCE -- WITHIN 3 SPEAKER: ATUL SHAH, SENIOR VICE PRESIDENT,STRATEGIC CLIENT DEVELOPMENT WITHIN 3 SHAH: It's great to have the opportunity to talk with you all about online communities. It's a topic that's near and dear to my heart. So, the -- the p…

3012. Chapter 5. Implement the VTE Prevention Protocol | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide5.html
      October 01, 2022 - Preventing Hospital-Associated Venous Thromboembolism Chapter 5. Implement the VTE Prevention Protocol Previous Page Next Page Table of Contents Preventing Hospital-Associated Venous Thromboembolism Preface Executive Summary Chapter 1. The Framework for Improvement Chapter 2. Analyze Care De…

3013. Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Deis_82.pdf
      June 03, 2008 - Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement Jamie N. Deis, MD; Keegan M. Smith, MD; Michael D. Warren, MD; Patricia G. Throop, BSN, CPHQ; Gerald B. Hickson, MD; …

3014. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
      January 01, 2024 - Spotlight Spotlight Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency 1 Source and Credits This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Jaenic Lee, MD Josh Fernel…

3015. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. | PSNet
      psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
      January 29, 2021 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. Citation Text: Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…

3016. Making Healthcare Safer IV Rapid Response: Acute Care Nursing Staff Shortages That Compromise Patient-to-Nurse Ratios (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/nursing-staff-shortages-rapid-research.pdf
      April 01, 2025 - winter 2012 and 8 days [SD 11] during summer 2012 [p < 0.01]), and a decrease in mean triage delay (7 minutes … [SD 33] during winter 2012 and 3 minutes [SD 33] during summer 2012 [p < 0.01]). … implementation of mandatory minimum staffing ratios.34 One study showed an increase in nursing time by 58 minutes … with decreased nurse staffing turnover,25 increased satisfaction,25 increased nursing time of 58 minutes

3017. CAHPS Moving Forward: Innovations in Tools and Research (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-moving-forward-webcast.pdf
      October 01, 2017 - We have just a few more minutes in this segment, so let me just throw out a couple of questions I think … So we have a number of other questions that we're going to try to get to within our remaining ten minutes … We are very close to the end of our 90 minutes, and I think we've tried to cover as many of the questions

3018. Initial Baseline Screen of Nutritional Status for Every Patient Within 24 Hours of Pediatric Intensive Care Unit (PICU) Admission (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-199-fullreport.pdf
      November 01, 2017 - hospitalized children (including institution-derived nutrition screening tools) typically take about 5 minutes … (most available screening tools) “…take about 5 minutes to administer, can be done at the bedside, and … hospitalized children (including institution-derived nutrition screening tools) typically take about 5 minutes

3019. Final Progress Report: Evaluate the Effects of the Massachusetts Reporting System (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/ridley-report.pdf
      January 01, 2024 - Each month, the project team leader met in a “huddle” (15 minutes) with the administrators responsible … Interviews took, on average, 20 minutes to complete. … On average, the interviews took 25 minutes to complete.

3020. Implementing PCOR To Increase Referral, Enrollment, and Retention in Cardiac Rehabilitation Through Automatic Referral With Care Coordination (pdf file)
      www.ahrq.gov/sites/default/files/publications2/files/takeheart-hybrid-workgroup-evaluation.pdf
      August 01, 2023 - Implementing PCOR To Increase Referral, Enrollment, and Retention in Cardiac Rehabilitation Through Automatic Referral With Care Coordination e Implementing PCOR To Increase Referral, Enrollment, and Retention in Cardiac Rehabilitation through Automatic Referral with Care Coordination Hybrid CR Workgroup Evalu…