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2141. 047-Ss-Faqs-Staff-Safety-Side-Effects (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/047-ss-faqs-staff-safety-side-effects.docx
      April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI Preoperative Decolonization Staff – Frequently Asked Questions: Safety and Side Effects Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries​ The products we are recommending for surgical site infection (SSI) preven…

2142. Job Aid: Process Mapping (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-process-mapping.pdf
      June 02, 2025 - Job Aid: Process Mapping Primary Care Practice Facilitator Training Series 1 Job Aid: Process Mapping Overview Process mapping, also called workflow mapping, allows a practice to "see" an entire work process from beginning to end. When to use process mapping Use process mapping to help a p…

2143. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-facguide.docx
      January 01, 2017 - reporting systems, sentinel events, and claims data are reactive—the unfortunate event has already occurred

2144. Transitioning Newborns from NICU to Home: Family Information Packet, Appendix B (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb.pdf
      June 02, 2025 - Transitioning Newborns from NICU to Home: Family Information Packet, Appendix B Appendix B: Clinical Materials to Share With Primary Care Providers Diagnoses and Conditions ■ Anemia of Prematurity ■ Apnea of Prematurity ■ Bronchopulmonary Dysplasia ■ Gastroesophageal Reflux ■ Nephrocalcinosis ■ Patent D…

2145. Improving Error Reporting in Ambulatory Pediatrics with a Team Approach (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Neuspiel_43.pdf
      March 05, 2008 - pediatric emergency department in Canada, 100 prescribing errors and 39 medication administration errors occurred

2146. Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdf
      January 01, 2005 - means of reducing them, root cause analysis provides indepth insight into errors that have actually occurred—in … technique is used reactively, to probe the reason for a bad outcome or for problems that have already occurred

2147. Selected Best Practices and Suggestions for Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4k_combo_psi14-dehiscence-bestpractices.pdf
      May 20, 2016 - Selected Best Practices and Suggestions for Improvement Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety 1 Tool D.4k Selected Best Practices and Suggestions for Improvement PSI 14: Postoperative Wound Dehiscence Why Focus on Postoperative Wound Dehiscence? • Postop…

2148. Improving Patient Safety in Long-Term Care Facilities, Module 3 (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/ltcmodule3.pdf
      June 01, 2012 - Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Knowing When a Fall Has Occurred … Knowing When a Fall Has Occurred A person can end up on the ground for many reasons.

2149. 26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Simmons_66.pdf
      April 03, 2008 - that explain why employees may not report errors: (1) fear, (2) disagreement over whether an error occurred … Also, because historically reports were submitted only when an actual error had occurred, a “change

2150. Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-facguide.html
      March 01, 2017 - When reckless behavior has occurred, it must be met with remedial or punitive action to decrease or eliminate

2151. Facilitator-Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module1/facilitator-notes.docx
      March 01, 2017 - When reckless behavior has occurred, it must be met with remedial or punitive action to decrease or eliminate

2152. Grantees Focusing on Hispanic and Latino Populations | Agency for Healthcare Research and Quality
      www.ahrq.gov/priority-populations/observances/hispanic-heritage/index.html
      October 01, 2021 - Grantees Focusing on Hispanic and Latino Populations   Peter Yellowlees, M.D. “I have found it fascinating to see the way that almost all patients speak differently, using simpler phrases and less words, when using an interpreter. Their descriptions of clinical symptoms and histories is much ric…

2153. Healthy Living: Infant Mortality | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/womenhealth/wm-hl.html
      September 01, 2015 - Chartbook on Women's Health Care Healthy Living: Infant Mortality Previous Page Next Page Table of Contents Chartbook on Women's Health Care Acknowledgments Women's Health Care Key Findings of the 2014 QDR 2014 Chartbooks Access to Health Care Affordability Communication and Care Coo…

2154. Operating Room Briefing and Debriefing Audit Tool | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/or-briefing-audit.html
      December 01, 2017 - Operating Room Briefing and Debriefing Audit Tool AHRQ Safety Program for Surgery Introduction Problem Statement One of the strongest determinants of safety culture is whether local and hospital leadership respond to staff patient safety concerns. Frontline providers understand patient safety …

2155. Developing a Community-Wide Electronic Shared Medication List (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Stock_113.pdf
      June 15, 2005 - the electronic tool by patients and clinicians; measure the degree to which medication discrepancies occurred … Electronic Medication List The clinic medication process-mapping phase and technical development of tools occurred … In summary, leadership observed that an organizational transformation occurred from fear of including … Health Care Clinics Two major improvements occurred in the clinic setting: (1) the clinic medication

2156. 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/guide.html
      December 01, 2017 - high risk or had a recent change in risk, would we do things differently to intervene before the event occurred

2157. Department of Veterans Affairs Emergency Airway Management Initiative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Stalhandske_71.pdf
      February 23, 2008 - These claims included some cases that occurred within the operating room. … Our database was unable to differentiate those that occurred due only to emergency airway management.b

2158. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/creating-safety-culture/cultureofsafety_hemodialysis.pptx
      September 03, 2014 - In determining what defect occurred, teams reconstruct the timeline of the event by placing themselves … well as offering help to their peers.     42 Feedback Timely—give soon after the target behavior has occurred … promote a supportive climate, feedback must be:   Timely, and given soon after the target behavior has occurred … Try to view the world as they did when the event occurred.   Why did it happen? Step 1.

2159. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/using-checklists/checklistandauditslides.pptx
      September 03, 2014 - Facility A Checklists and monthly process audits were instituted Problem identified: Breaks in process occurred … In determining the defect that occurred, teams reconstruct the timeline of the event by placing themselves … Try to view the world as they did when the event occurred. Why did it happen? Step 1.

2160. Tool: OR Briefing and Debriefing Audit Tool (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/or_briefing_audit.docx
      December 01, 2017 - Tool: OR Briefing and Debriefing Audit Tool AHRQ Safety Program for Surgery Operating Room Briefing and Debriefing Audit Tool Introduction Problem Statement One of the strongest determinants of safety culture is whether local and hospital leadership respond to staff patient safety concerns. Frontline providers unde…