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361. 152-Cusp-Tip-Sheet-Engaging-Physicians (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/152-cusp-tip-sheet-engaging-physicians.docx
     October 01, 2024 - AHRQ Safety Program for MRSA Prevention CUSP Tip Sheet: Engaging Physicians in MRSA Prevention ICU & Non-ICU Issue1-5 Physicians play crucial roles in quality and safety, as leaders, champions, committee members, and participants in planning and executing change. Each role is vital in the success of any undertaking to…

362. Enabling Real-Time Identification of Burnout Risk Among Clinicians in Primary Care Practices | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/about/impact-stories/enabling-real-time.html
     April 01, 2025 - Enabling Real-Time Identification of Burnout Risk Among Clinicians in Primary Care Practices AHRQ Impact: Researchers have developed a prediction tool to identify primary care practices at high-risk of clinician burnout. Instead of relying on clinician surveys that increase burden, the tool enables…

363. Measure Descriptions for Daily Early Mobility: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/daily-early-mobility-fac-guide.html
     February 01, 2017 - measurement, it’s recommended to choose the value closest to 10 a.m. because this is usually when rounds occur … performed, it’s recommended to choose the value closest to 10 a.m. because this is usually when rounds occur

364. Validation of AHRQ’s Patient Safety Indicator for Accidental Puncture or Laceration (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Gallagher1.pdf
     January 01, 2004 - concern was that, while the intent of the APL PSI is to identify all punctures and lacerations that occur … validation of the indicator intended to identify cases of accidental puncture or laceration (APL) that occur … Because the intent of the indicator is to identify cases that occur after admission, Table 1. … Human: Building a Safer Health System,30 there has been an emphasis on identifying adverse events that occur … reviewers was that, while the intent of the APL PSI is to identify all punctures and lacerations that occur

365. Chapter 2. Fall Response | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html
     December 01, 2017 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities Chapter 2. Fall Response Previous Page Next Page Table of Contents The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities Chapter 1. Introduction and Program Overview Chapter 2. F…

366. Accessible Facilitator Guide: Learn From Defects for Sustainability (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
     December 01, 2017 - For factors that occur often and impact a significant percentage of cases in your unit, place it in the

367. Sustainability: Learning From Defects: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
     December 01, 2017 - For factors that occur often and impact a significant percentage of cases in your unit, place it in the

368. Final Progress Report: Effects of Extended Work Hours on ICU Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/czeisler-report.pdf
     January 01, 2024 - Intrasubject comparison will occur to document the effects of fatigue on medical decision making and … Intersubject comparison will also occur to investigate the types of errors most often made in rested

369. NICU Family Information Packet, Appendix B, Anemia of Prematurity (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-anemia.pdf
     June 02, 2025 - NICU Family Information Packet, Appendix B, Anemia of Prematurity Anemia Of Prematurity Characteristics ■ Occurs during the normal developmental switch from fetal to adult hemoglobin synthesis. ■ Immediately after birth, the increase in blood oxygen content results in the downregulation of erythropoietin. ■ On…

370. Strategy 3: Nurse Bedside Shift Report (Tool 1) (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_1_BSR_Broch_508.docx
     June 02, 2025 - Nurse shift changes occur when nurses who are going off duty share information about your care with nurses

371. NICU Family Information Packet, Appendix B, Neurodevelopment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-neurodevt.pdf
     June 02, 2025 - visual-motor integration and neuromotor and cognitive functions; problems with behavior and temperament may occur

372. Improving Diagnosis in the Context of Rurality | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-rural-healthcare2.html
     October 01, 2024 - that 33 percent  of diagnostic errors result in patient injury, 22 and 57 percent of these failures occur

373. PowerPoint Presentation: Learn From Defects for Sustainability
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptx
     December 01, 2017 - For factors that occur often and impact a significant percentage of cases in your unit, place it in the

374. Implementation Quick Start Guide: Warm Handoff Plus (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-quick-start-final508.pdf
     June 02, 2025 - Evaluate implementation success � How often does the intended Warm Handoff Plus occur?

375. Introducing TeamSTEPPS Introduction
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-introduction-slides.pptx
     June 02, 2025 - Describe the impact of errors and why they occur. Describe the TeamSTEPPS framework.

376. Asthma 1 Measure Calculation Steps (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/flow-diagrams.pdf
     June 02, 2025 - This means, for a given member-month, a comorbidity may occur in the future (but only within the same

377. Final Progress Report: Quality Care and Error Reduction in Rural Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/cook-hoas-report.pdf
     January 01, 2024 - responded to the needs of rural healthcare providers to know what kinds of errors are most likely to occur … settings and identify the conditions, including working conditions, under which system change can occur … Our study showed that three key conditions must be met in order for system change to occur: (1) shared … can be handled; (3) belief that organizational changes, or corrective actions, are possible and will occur … care in one’s hospital is safe) so that they can recognize the full range of errors that actually occur

378. Final Progress Report: Developing and Training Interruption Management Strategies for Emergency Physicians (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/ratwani-report.pdf
     January 01, 2024 - demonstrate that emergency physicians are interrupted frequently and that these interruptions typically occur

379. Methodological Challenges in Describing Medication Dosing Errors in Children (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/McPhillips.pdf
     January 01, 2004 - prescribed in ambulatory settings, little is known about the frequency and types of medication errors that occur … appropriate frequency for the medication; (6) communication with the parent or caregiver often will occur … Tenfold dosing errors in children can easily occur due to a misplaced decimal point or a trailing zero … United States, very little information is available on the epidemiology of medication errors that occur

380. Final Progress Report: Risk Analysis of Pediatric Chemotherapy Processes (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdf
     January 01, 2024 - members for severity (effect to the patient if the failure occurred), occurrence (how often does this occur … Documented infrequently; the condition has a reasonable chance to occur. … The condition will inevitably occur during long periods typical for the step or link. … regimens often have upward of 10 to 20 individual component orders, which commonly must be specified to occur