-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/learning_pt_narratives_053123-nembhard.pdf
June 02, 2025 - Learning from Patient Narratives Through Innovative Feedback Reporting Methods Webcast - Impact of the Intervention on Staff Experience
Impact of the Intervention on Staff Experience
Ingrid Nembhard, PhD
Professor of Health Care Management
The Wharton School
University of Pennsylvania
Data Collection: Staff Sur…
-
www.ahrq.gov/sites/default/files/2024-01/carayon-report.pdf
January 01, 2024 - sharing of tasks in which one nurse scans and another
administers or in which scanning and documenting occur
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Cook.pdf
January 01, 2004 - Hoas, Katarina Guttmannova
Abstract
To date, few studies have focused on patient safety issues that occur … case studies, also e-mailed to team
members, were based on the kinds of patient safety issues that occur … blameless way for health care providers to
present and discuss patient safety issues that could—and did—occur … As a result, decisions about recognizing,
reporting, and disclosing errors that occur in rural health
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings.pptx
December 01, 2017 - They are an opportunity to LISTEN to the wisdom of your frontline providers as defects occur.
2
Safety … By default, they occur at the beginning of a case to ensure every member of the care team is on the same … Huddles occur on an emergent or as-needed basis. … Brief, informal information exchange and feedback sessions
Occur after an event or shift
Stress learning … Different sections can occur at different times.
-
www.ahrq.gov/sites/default/files/2024-02/mackenzie-report.pdf
January 01, 2024 - Final Progress Report: Brief, Risky, High-Benefit Procedures: Best Practice Model
Final Progress Report
Brief, Risky, High-Benefit Procedures:
Best Practice Model
Colin F. Mackenzie, MD, Principal Investigator
Co-investigators: Yan Xiao, PhD, Grant Bochicchio, MD,
Peter Hu, MS, CNE, F. Jacob Seagull, PhD…
-
www.ahrq.gov/news/newsroom/press-releases/chlorhexidine-bathing.html
October 01, 2023 - healthcare-associated infections (HAIs) such as MRSA, bloodstream infections, and urinary tract infections occur
-
www.ahrq.gov/hai/cusp/videos/05h-why-did-happen/index.html
June 01, 2018 - Why Did It Happen?
CUSP Toolkit
The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit.
Apply CUSP To Find Out W…
-
www.ahrq.gov/sites/default/files/2024-12/danforth-report.pdf
January 01, 2024 - have primarily focused on inpatient settings;
however, an estimated one billion outpatient visits occur … Results: In outpatient settings, care gaps (or deviations from “ideal” care) occur
regularly enough
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0232-technicalspecs.pdf
June 02, 2025 - Hypertension Screening for Children Who Are Overweight or Obese: Technical Specifications
The percentage of children aged 3 through 17 years with an outpatient care visit and a BMI ≥85th
percentile who had a blood pressure percentile documented and classified as normal or abnormal during
the measure…
-
www.ahrq.gov/cahps/surveys-guidance/item-sets/literacy/suppl-interpreter-service-items-hp-survey50-adult.html
April 01, 2020 - Some items cover events that occur with low frequency in the general population.
-
www.ahrq.gov/cahps/surveys-guidance/item-sets/literacy/suppl-interpreter-service-items.html
October 01, 2023 - Additionally, some items cover events that occur with low frequency in the general population.
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/7.html
December 01, 2017 - Limited Assistance (LA)
Extensive Assistance (EA)
Total Dependence (Total)
Activity Did Not Occur … No setup (None)
Set up only (Set up)
One person (1)
Two person (2)
Activity Did Not Occur
-
www.ahrq.gov/hai/tools/surgery/modules/implementation/audit-briefing-slides.html
December 01, 2017 - When did briefing occur? … When did briefing occur?
Before patient entered.
Before induction.
Before incision.
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/penicillin-allergy-one-pager.pdf
September 01, 2022 - How soon after taking the antibiotic did the reaction occur?
3.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Chan.pdf
January 01, 2004 - Post-fielding Surveillance of a Guideline-based Decision Support System
331
Post-fielding Surveillance of a Guideline-
based Decision Support System
Albert S. Chan, Susana B. Martins, Robert W. Coleman, Hayden B.
Bosworth, Eugene Z. Oddone, Michael G. Shlipak, Samson W. Tu,
Mark A. Musen, Brian B. Hoffman, …
-
www.ahrq.gov/teamstepps-program/curriculum/communication/tools/index.html
July 01, 2023 - Shift or staff changes: Transitions in care are the times when most communication breakdowns occur. … Where did miscommunication occur in this situation?
What are the possible outcomes?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheetinstructions.pdf
June 02, 2025 - Ideally, if your
data permit, consider only costs that occur after the adverse event occurred.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf
June 02, 2025 - Ideally, if your
data permit, you would consider only costs that occur after the adverse event occurred
-
www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/slides.html
October 01, 2020 - Often times spread and sustainability may occur concurrently. … Speak up when a potential break in patient safety protocol may occur or actually occurs.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Lapane.pdf
March 09, 2005 - that jeopardize patient safety
are common in nursing homes.16 Gurwitz et al.17 estimated that ADEs occur … ADEs occur despite the fact that CMS
requires that the drug regimen of each resident be reviewed monthly … this stage of the medication use
process are warranted, because of all preventable ADEs, 70 percent occur … at
predetermined intervals (e.g., at admission, quarterly, when significant changes in
condition occur