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2521. Final report: To Quantify the Impact of the Existing vs. Enhanced Work Configuration of Radiation Therapy Technicians on Workload, Situation Awareness, and Performance during Pretreatment QA Tasks (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/mosaly-report.pdf
      January 01, 2024 - Errors in RT are estimated to occur in up to ≈ 5% of the > ≈600,000 patients receiving RT per year in

2522. Primary Care Practice Facilitation Curriculum Module 4: An Introduction to Practice Organization and Management (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-4-practice-management.pdf
      September 01, 2015 - Primary Care Practice Facilitation Curriculum Module 4: An Introduction to Practice Organization and Management Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov Primary Care Practice Facilitation Curriculum Module 4: An Introduction to Practice Organization a…

2523. Implementing the New CAHPS Protocol for Obtaining Patient Comments About Their Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/implementing-new-protocol-transcript.pdf
      October 01, 2018 - Implementing the New CAHPS Protocol for Obtaining Patient Comments About Their Care Implementing the New CAHPS Protocol for Obtaining Patient Comments About Their Care October 2018  Webcast Speakers Caren Ginsberg, PhD, Director, CAHPS Division, Center for Quality Improvement and Patient Safety, Agency for H…

2524. Fielding the CAHPS Child Hospital Survey (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hospital/about/fielding-child-hcahps-93.pdf
      June 02, 2025 - If multiple discharges occur within the same timeframe of the list (e.g., a patient has two separate

2525. Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Webster_76.pdf
      July 18, 2008 - Typically, when a brief does not occur, staff members presume what is going to happen; new or inexperienced

2526. Is There an Association Between Patient Safety Indicators and Hospital Teaching Status? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Rivard_97.pdf
      April 28, 2008 - teaching hospitals.3, 4 Based on these studies, we hypothesized that PSI events would be more likely to occur

2527. Hybrid Cardiac Rehabilitationi (HYCR) Tools and Resources Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/hycr-tools-resources-guide.pdf
      June 02, 2025 - Patient/family was informed of the general low risk of injury that can occur while using exercise equipment … Patient/family was informed of the general low risk of injury that can occur while using exercise equipment … Important Terms That I Agree To • I understand that technical difficulties can occur which may result

2528. Using Rapid-Cycle Research to Reach Goals: Awareness, Assessment, Adaptation, Acceleration (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/final-rapid-cycle-research-guidance.pdf
      June 01, 2015 - manufacturing, managers walk through the factory to better understand how bottlenecks and defects occur … These actions occur smoothly because the players practice so often. … We see similarities in how good hand-offs occur if we take the football teams’ solutions and apply … Data quality problems can occur from lack of http://pbrn.ahrq.gov/events/how-pragmatic-it-lessons-learned-using-precis-and-re-aim-determining-pragmatic

2529. 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

2530. 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.

2531. Translating Patient Safety Research into Clinical Practice (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Magid.pdf
      January 01, 2004 - Of these adverse events, 25 to 75 percent were preventable.2, 13, 17 Errors can occur at several

2532. 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

2533. 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

2534. 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

2535. 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

2536. 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

2537. 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.

2538. 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

2539. 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

2540. 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