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2401. Implementation of an Evidence-based Protocol for Surgical Infection Prophylaxis (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Savino.pdf
      July 01, 2003 - Since most infections will occur after discharge from the hospital, voluntary reporting by surgeons

2402. Patient Safety Executive Walkarounds (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Graham.pdf
      April 01, 2004 - simply avoid errors; it also is important to identify and report potential causes of errors before they occur

2403. Improving Patient Safety Using ATHENA-Decision Support System Technology: The Opioid Therapy for Chronic Pain Experience (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Michel_92.pdf
      April 30, 2008 - errors resulting from the technology, thoughtful development and careful testing of the system must occur

2404. Section 5: Determining Where To Focus Efforts To Improve Patient Experience (Page 2 of 2) | Agency for Healthcare Research and Quality
      www.ahrq.gov/cahps/quality-improvement/improvement-guide/5-determining-focus/section5part2.html
      January 01, 2020 - Document the steps as they actually occur.

2405. 053-Dec-Guide-Readiness (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/053-dec-guide-readiness.docx
      October 01, 2024 - The Centers for Disease Control and Prevention (CDC) defines attribution to a unit as events that occur

2406. Final Progress Report: Improving Transplant Med Safety through a Pharmacist-Led, mHealth-Based Program (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/taber-report.pdf
      January 01, 2024 - med errors (taking a med in a manner not intended), predominantly due to patient-related factors, occur

2407. Module-6-Implementation-Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-6-implementation-guide.pdf
      June 02, 2025 - referral by referring physicians, patients and their families and ensuring formal referrals actually occur

2408. Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Sirio.pdf
      June 15, 2003 - that both prevents errors Advances in Patient Safety: Vol. 3 154 and learns from them as they occur

2409. Continuous Respiratory Monitoring and a “Smart” Infusion System Improve Safety of Patient-Controlled Analgesia in the Postoperative Period (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_111.pdf
      June 18, 2008 - Part I: How errors occur. ISMP medication safety alert; 2003 July 10.

2410. Final Progress report: Creating High Reliability Organizations (pdf file)
      www.ahrq.gov/sites/default/files/2024-03/small-report.pdf
      January 01, 2024 - Additional sharing of results will occur at regional and national meetings and will inform local systems

2411. National Opportunity To Improve Infection Control in ESRD (NOTICE) Phase Two Final Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/finalreportphase2.pdf
      September 29, 2014 - activities from both project phases directly contribute to the overall goal of reducing infections that occur

2412. Improving Customer Service and Access in a Surgical Practice (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/reports-and-case-studies/Case_Study_Specialty_Practice_Updated.pdf
      October 01, 2011 - Improving Customer Service and Access in a Surgical Practice WORKING P A P E R Improving Customer Service and Access in a Surgical Practice A Case Study of a Successful Quality Improvement Intervention Denise D. Quigley, Shelley H. Wiseman, and Donna O. Farley WR-848-AHRQ August 2011 Prepared for th…

2413. Consumer Assessment of Healthcare Providers and Systems Hospital Survey--Child Version (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-140-fullreport.pdf
      November 02, 2017 - Consequently, CAHPS surveys do not address aspects of care that rarely occur.

2414. Case 5. Heights Hospital | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case5.html
      November 01, 2014 - Steps 1 through 10 occur as part of the training, and steps 11 through 13 continue and close the project

2415. Inventory and Prioritization of Measures To Support the Growing Effort in Transparency Using All-Payer Claims Databases (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/prioritization-report_0.pdf
      January 01, 2020 - This situation can occur due to carve-outs, multiple coverage for one individual, duplicate claims, … Some data cleaning undertaken by the APCD or the user will remove real multiple encounters that occur

2416. Final Progress Report: The National Quality Forum National Annual Policy Conference 2007 (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/feeney-report.pdf
      January 01, 2025 - Overall, an estimated 2 million hospital-acquired HAIs occur each year in the United States, accounting

2417. Final Progress Report: Making Acute Care More Patient Centered, Patient Safety Learning Laboratory (PSLL) (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/bates3-report.pdf
      January 01, 2024 - and incident reporting systems in the hospital, to proactively mitigate safety risks before incidents occur

2418. Session 2 | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod1sess2.html
      October 01, 2014 - Module 1: Detecting Change in a Resident's Condition Session 2 Previous Page Next Page Table of Contents Module 1: Detecting Change in a Resident's Condition Learning and Performance Objectives Session 1 Session 2 Conclusion Additional Tools and Resources Changes That Matte…

2419. Spreading Lean: Taking Efficiency Interventions in Health Services Delivery to Scale - Executive Summary (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/execsumm-lean-redesign.pdf
      March 01, 2017 - Spreading Lean: Taking Efficiency Interventions in Health Services Delivery to Scale - Executive Summary Executive Summary Spreading Lean: Taking Efficiency Interventions in Health Services Delivery to Scale Prepared for: Agency for Healthcare Research and Quality 5600 Fishers Lane …

2420. On-Time Pressure Ulcer Healing: Facilitator Training Instructor's Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/facguide.html
      December 01, 2017 - On-Time Pressure Ulcer Healing: Facilitator Training Instructor's Guide AHRQ’s Safety Program for Nursing Homes: Implementation of the Healing Reports Note: This part of the training primarily consists of exercises and does not have any associated slides. Review of Self-Assessment Worksheet Say:   Y…