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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…
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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…
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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…
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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…
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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
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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
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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.
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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
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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…
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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
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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
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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…
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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…
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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 …
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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
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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
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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
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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.
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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.
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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…