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  1. digital.ahrq.gov/sites/default/files/docs/publication/r21hs018214-olson-final-report-2012.pdf
    January 01, 2012 - Messages were planned to not occur during school and were provided at 7:30 AM, 3pm, 5pm, and 9 pm … Further study needs to occur in more ethnically and racially diverse settings.
  2. digital.ahrq.gov/ahrq-funded-projects/enhancing-providers-ability-followup-abnormal-test-results
    January 01, 2023 - Appropriate and timely follow up of abnormal results must occur to achieve the full benefit of cancer
  3. digital.ahrq.gov/ahrq-funded-projects/surveillance-adverse-drug-events-ambulatory-pediatrics
    January 01, 2023 - Surveillance for Adverse Drug Events in Ambulatory Pediatrics Project Final Report ( PDF , 941.73 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views …
  4. digital.ahrq.gov/ahrq-funded-projects/assessing-impact-patient-centered-medical-home-mn
    January 01, 2023 - Assessing the Impact of the Patient-Centered Medical Home Project Description Annual Summaries Publications Project Details - Completed Contract Number 290-07-10010-4 Funding Mechanism(s) Primary Care Practice-Based Research…
  5. digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/comms-usage-diagram
    January 01, 2023 - Comms Usage Diagram Acronym CUD Description A comms usage diagram (CUD) displays how teams in different geographical areas collaborate across their respective locations. The diagram also includes information about how and why the communication occurs, the specific technology being used, and th…
  6. digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/workflow-diagram
    January 01, 2023 - Workflow Diagram Also Known As Physical Layout Flowchart Spaghetti Diagram Transportation Diagram Description A workflow diagram demonstrates movement through a process. The diagram is comprised of a map (such as a floor plan) of the area where the process occurs and uses lines to show…
  7. digital.ahrq.gov/sites/default/files/docs/citation/r01hs026732-usher-final-report-2023.pdf
    January 01, 2023 - high-risk transition of care is a setting in which breakdowns in the diagnostic process are likely to occur … Since inter-hospital transfers occur within a single day, and provide data from two unique assessments
  8. digital.ahrq.gov/ahrq-funded-projects/multi-site-trial-test-benefits-adding-personalized-risk-calculator-online
    July 31, 2025 - Usability testing will occur among patients, caregivers, LVAD coordinators, and physicians to collect
  9. digital.ahrq.gov/ahrq-funded-projects/medication-reconciliation-improve-quality-transitional-care/annual-summary/2010
    January 01, 2010 - This significant source of error can cause injury or even fatalities and can occur in all types of health
  10. digital.ahrq.gov/ahrq-funded-projects/implementing-low-literacy-multimedia-information-technology-it-system-enhance/annual-summary/2010
    January 01, 2010 - This survivorship care planning is designed to minimize the interruptions in care that can occur when
  11. digital.ahrq.gov/ahrq-funded-projects/integris-telewoundcare-network/annual-summary/2008
    January 01, 2008 - If blood sugars are too high, healing will not occur; thus, controlling blood sugars should be addressed
  12. Layout 1 (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/08-0093_cpoe.pdf
    August 01, 2008 - Order entry errors can occur, for example, when providers order medications that adversely interact with
  13. digital.ahrq.gov/ahrq-funded-projects/assessing-impact-patient-centered-medical-home/annual-summary/2010
    January 01, 2010 - Assessing the Impact of the Patient-Centered Medical Home - 2010 Project Name Assessing the Impact of the Patient-Centered Medical Home Principal Investigator Fontaine, Patricia Organization University of Minnesota Contract Number 290-07-10010-4 Project Period…
  14. Layout 1 (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/08-0085_bcma.pdf
    August 01, 2008 - These errors can occur at any stage in the process of medication use (e.g., prescribing, dispensing,
  15. digital.ahrq.gov/sites/default/files/docs/publication/r18hs017010-bailey-final-report-2011.pdf
    January 01, 2011 - high-alert medications – particularly anticoagulants – are a frequent cause of hospitalization.(4) ADEs occur … pharmacists frequently need to repackage adult preparations, thus adding more opportunities for errors to occur … Narcotics overdoses occur in both inpatient and outpatient settings with some frequency due to clinician
  16. digital.ahrq.gov/decisionmaker-brief-computerized-provider-order-entry-cpoe
    January 01, 2023 - Order entry errors can occur, for example, when providers order medications that adversely interact with
  17. digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015319-sullivan-final-report-2007.pdf
    January 01, 2007 - error” (NCC MERP Level A14 A priori, we had posited that the error characteristics most likely to occur
  18. digital.ahrq.gov/ahrq-funded-projects/integrating-contextual-factors-clinical-decision-support-reduce-contextual
    January 01, 2023 - Contextual errors occur when a care plan is inappropriate because of inattention to patient context.
  19. digital.ahrq.gov/ahrq-funded-projects/scaling-and-spreading-electronic-capture-patient-reported-outcomes-leveraging
    January 01, 2024 - Scaling and Spreading Electronic Capture of Patient-Reported Outcomes Leveraging a National Surgical Quality Improvement Program Project Final Report ( PDF , 983.41 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are respons…
  20. digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/root-cause-analysis
    January 01, 2023 - Root Cause Analysis Acronym RCA Examples Latino RJ. The "5 PS" concept. Patient safety: the PROACT root cause analysis approach. Boca Raton, FL: CRC Press; 2009. p. 77-86. Latino RJ. Case studies. Patient safety: the PROACT root cause analysis approach. Boca Raton, FL: CRC Press; 2009. p. …

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