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701. HAC National Scorecard 2014-16 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-scorecard-2014-16.pdf
     January 01, 2014 - HAC National Scorecard 2014-16 8,000 Inpatient Deaths Averted HAC National Scorecard 2014-16 Between 2014-2016, 350,000 fewer hospital-acquired conditions (HACs) occurred, an 8% decrease that saved $2.9 billion and averted 8,000 inpatient deaths. Learn more in the AHRQ report “National Scorecard on Rates of H…

702. The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
     March 27, 2008 - These events occur for a variety of reasons, such as poorly designed systems, inadequate training, communication … One study estimated that 1,200 to 2,700 events occur annually in the United States.20 Based on a review … Increasingly complex and invasive procedures now occur routinely in other settings, particularly imaging

703. Understand the Science of Safety for Perinatal Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-slides.html
     July 01, 2023 - Understand the Science of Safety for Perinatal Safety AHRQ Safety Program for Perinatal Care Slide 1: AHRQ Safety Program for Perinatal Care Understand the Science of Safety for Perinatal Safety Slide 2: Learning Objectives Image: Four ascending steps show the learning objectives: Describe the h…

704. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits - Functional Specifications (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallspxspecs.pdf
     February 01, 2018 - Limited Assistance (LA) • Extensive Assistance (EA) • Total Dependence (Total) • Activity Did Not Occur … Limited Assistance (LA) • Extensive Assistance (EA) • Total Dependence (Total) • Activity Did Not Occur … value by taking the highest (or worst) value recorded for that week: • Do no use Activity Did Not Occur

705. Transcript: How To Empower Nurses To Effectively Implement a Nurse-Driven Protocol for Removing Urinary Catheters, Including How To Obtain Buy-In From Physicians (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/empowering-nurses-transcript.pdf
     April 01, 2022 - So, we have incorporated that question into our interdisciplinary rounds that occur each day on our

706. Recruitment Process Diagram Northwest (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/recruitment-timeline-nw.pdf
     June 19, 2015 - Recruitment Process Diagram Northwest Draft H2N Recruitment Process Flow June 19, 2015 Practice completes interest form Interest form is received in H2N email box Recruiter sends an email to practice scheduling time for a phone conversation, provides some additional information about H2N via email…

707. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-reimagining-healthcare-teams-1.html
     July 01, 2023 - Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety Introduction Previous Page Next Page Table of Contents Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety Introduction The Patient-Clinician Dy…

708. Gap Analysis Facilitator's Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3.html
     August 01, 2022 - Discussion about who should participate in each gap analysis focus group should occur early (at least

709. CLABSI and CAUTI Learning Tools | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/clabsi-cauti-icu/implement/learning-tools.html
     February 01, 2025 - CLABSI and CAUTI Learning Tools This step identifies two types of tools that can be revisited any time a central line-associated bloodstream infection (CLABSI) or catheter-associated urinary tract infection (CAUTI) occurs on your unit. They both support a thorough review of the event to identify and address the…

710. Cover slide
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP-Patient-Family-Engagement.pptx
     May 01, 2013 - education Organizations should be prepared to respond and communicate proactively when adverse events occur

711. PowerPoint Presentation: Best Practices in the Diagnosis and Treatment of Community-Associated Lower Respiratory Tract Conditions
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/respiratory-slides.pptx
     November 01, 2019 - PowerPoint Presentation: Best Practices in the Diagnosis and Treatment of Community-Associated Lower Respiratory Tract Conditions Best Practices in the Diagnosis and Treatment of Community-Associated Lower Respiratory Tract Conditions Acute Care AHRQ Safety Program for Improving Antibiotic Use AHRQ Pub. No. 17(20)-00…

712. AHRQ Mastectomy SB Infographic v15 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/double-mastectomy.pdf
     February 01, 2016 - AHRQ Mastectomy SB Infographic v15 As this infographic shows, the rate of double mastectomies per 100,000 women more than tripled between 2005 and 2013. Mastectomies overall – both single and double mastectomies – increased 36 percent during that period. The rise in mastectomies occurred despite breast cancer…

713. Chapter 5 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter5.html
     August 01, 2022 - regarding the circumstances, caveats, and limitations for when public reporting should or should not occur … The systems could flag reports that occur significantly after the event, which may be used differently

714. AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/overviewhandouts2.html
     December 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Handouts: Overview of On-Time (continued) Self-Assessment Worksheet Section 1: Screening for Pressure Ulcer Risk Section 2: Pressure Ulcer Prevention Plan Section 3: Communication Practices Section 4: Investigations/Root Cause …

715. A Practical Guide for Estimating the Costs of Primary Care Transformation | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/research-transform-primary-care/transform/cost/guide.html
     October 01, 2015 - estimating the costs of primary care redesign, depending on whether efforts to implement or adapt EHRs occur

716. A Practical Guide for Estimating the Costs of Primary Care Transformation | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/reports/cost-guide/practical-guide.html
     February 01, 2017 - estimating the costs of primary care redesign, depending on whether efforts to implement or adapt EHRs occur

717. What Exactly Is Patient Safety? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf
     July 02, 2008 - The realization that adverse events often occur because of system breakdowns, not simply because of … therapeutic interaction.2 It also created a locked-in paralysis for all concerned when failure did occur … It is in the microsystem where the “sharp end” resides, where patient- caregiver interactions occur, … High- reliability designs are resilient even when unpredictable events occur. … care has developed many of these barriers, and usually several must be breached for patient harm to occur

718. Health and Economic Outcomes of Newborn Screening for Infantile-onset Pompe Disease | Agency for Healthcare Research and Quality
     www.ahrq.gov/priority-populations/publications/richardson-et-al-2020.html
     January 01, 2021 - Health and Economic Outcomes of Newborn Screening for Infantile-onset Pompe Disease Pompe disease is a rare condition that is identified in about 1 in 40,000 births. It occurs from a defect in the GAA gene leading to the accumulation of lysosomal glycogen and, depending on the form and severity, can result in c…

719. Science of Safety and Identifying Defects in Care of Mechanically Ventilated Patients: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/science-of-safety-fac-guide.html
     February 01, 2017 - Errors also occur because systems frequently are not designed to catch mistakes before they reach the

720. Chapter 3. Data Collection and Analysis Using TRIPS | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man3.html
     December 01, 2017 - Such details as location, time and activity may reveal that a large percentage of falls occur in one