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201. Cusp Patient Family Engagement Facilitator Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
     June 02, 2025 - SAY: The Patient and Family Engagement module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit focuses on an important topic: Making sure patients and their family members understand what is happening during the patient’s hospital stay, are active participants in the patient’s care, and are prepared for…

202. Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/brock.html
     August 01, 2017 - instrument does not assess the specific organizational factors that determine how, or if, change is occurring

203. Interim Update on 2013 Annual Hospital-Acquired Condition Rate (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014finalhacreport-cx.pdf
     December 01, 2016 - from 2011 to 2014 as a result of the reduction in HACs, with nearly $16 billion of those cost savings occurring

204. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
     December 01, 2016 - from 2011 to 2014 as a result of the reduction in HACs, with nearly $16 billion of those cost savings occurring

205. Conducting a Morning Briefing | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/morning-briefing.html
     December 01, 2012 - Conducting a Morning Briefing CUSP Toolkit Improve communication with nursing staff Problem statement: Physicians can improve communication with nursing staff while more efficiently prioritizing patient care delivery and admissions and discharges. What is a Morning Briefing? A morning briefing is a dial…

206. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
     January 01, 2003 - Development and Validation of the Medication Administration Error Reporting Survey 475 Development and Validation of the Medication Administration Error Reporting Survey Bonnie J. Wakefield, Tanya Uden-Holman, Douglas S. Wakefield Abstract Analysis of medication errors can lead to system improvement and reduc…

207. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
     July 01, 2023 - Patient and Family Engagement for Perinatal Safety: Facilitator Guide AHRQ Safety Program for Perinatal Care Slide 1: Patient and Family Engagement for Perinatal Safety Say: The Patient and Family Engagement module focuses on an important topic: making sure patients and their family members understand w…

208. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
     August 01, 2022 - Module 5: Response and Disclosure AHRQ Communication and Optimal Resolution Toolkit Facilitator Notes Say: In Module 5 of the CANDOR Toolkit, we will discuss the Response and Disclosure component of the CANDOR process. Slide 1 Say: The goal of this module is to: Define…

209. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
     May 19, 2003 - Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis 323 Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis Kathleen A. Harder, John R. Bloomfield, Sue E. Sendelbach, Michele F. Shepherd, Pam S. Rush, Jamie S. Sinclair,…

210. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
     January 01, 2024 - The fault tree is structured with data entry verification occurring after the data entry process and

211. Safe Medication Administration: Oxytocin | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/tool-safe-oxytocin.html
     July 01, 2023 - Examples include contractions lasting 2 minutes or more, contractions of normal duration occurring within … Contractions of normal duration occurring within 1 minute of one another.

212. 2022 National Healthcare Quality and Disparities Report Executive Summary (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-final-es.pdf
     October 01, 2022 - “Semisynthetic opioids” refer to substances synthesized from a naturally occurring opioid, such as oxycodone … refer to substances synthesized in a laboratory that act on the same targets in the brain as naturally occurring

213. Final Progress Report: Improving Safety of Transitions to Skilled Nursing Care Using Video Conferencing (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lipsitz-report.pdf
     January 01, 2024 - characteristics, and we performed separate analyses of outcomes before the pandemic and while it was still occurring

214. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
     January 01, 2017 - Presentation: Program Overview Learn From Defects in Care of Mechanically Ventilated Patients AHRQ Safety Program for Mechanically Ventilated Patients AHRQ Pub. No. 16(17)-0018-34-EF January 2017 Learn From Defects ‹#› AHRQ Safety Program for Mechanically Ventilated Patients 1 Learning Objectives After this ses…

215. 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 - This is a concern because the intent of the PSI is to capture all events occurring in the inpatient … To determine if the PSI is capturing all of the bladder lacerations occurring in hysterectomies, we

216. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
     August 01, 2022 - Implementation Guide for the CANDOR Process Communication and Optimal Resolution Toolkit Purpose: The Toolkit Implementation Guide is a reference for organizational leaders who are committed to improving their response to unexpected patient harm events. The guide describes the CANDOR process, implementatio…

217. Best Practices in the Management of Patients With Antibiotic Allergies – Facilitator Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/allergies-guide.docx
     September 01, 2022 - Best Practices in the Management of Patients With Antibiotic Allergies – Facilitator Guide AHRQ Safety Program for Improving Antibiotic Use 1 Best Practices in the Management of Patients with Antibiotic Allergies Ambulatory Care Slide Title and Commentary Slide Number and Slide Best Practices in the Managemen…

218. Final Progress Report: Analysis of Factors Associated With Clinical Checklist Compliance (pdf file)
     www.ahrq.gov/sites/default/files/2024-05/sarcevic-report.pdf
     January 01, 2024 - resuscitation that we previously designed,11,12 and we studied its use during live resuscitations occurring … Inaccurate checks accounted for 5% of all checked items, occurring for 14 of the 32 tasks (Table 2). … We defined a pre-check as the check-off timestamp occurring before the start time of the corresponding

219. Module-6-Slides (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-6-slides.pdf
     October 28, 2021 - • Are conversations occurring between patients and the referring clinician?

220. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
     May 01, 2011 - PowerPoint Presentation Communication and Optimal Resolution (CANDOR) Toolkit Module 6: Care for the Caregiver Module 6 includes information on the Care for the Caregiver component of the CANDOR process, which focuses on providing emotional support to caregivers following a CANDOR event. This module includes steps…