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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.
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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
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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 …
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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…
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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…
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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…
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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
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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
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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
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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
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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
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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
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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…
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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,
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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
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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
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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
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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.
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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…
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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. …