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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.htmlJuly 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…
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Final Progress Report: Physician Organization and the Efficiency of Surgical Specialty Care (pdf file)
www.ahrq.gov/sites/default/files/2024-02/miller-birkmeyer-report.pdfJanuary 01, 2024 - We defined operative mortality as death occurring within 30 days or before discharge from the index … differences in patient illness severity and their baseline “costliness,” we also adjusted for expenditures occurring … differences in patient illness severity and their baseline “costliness,” we also adjusted for expenditures occurring -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdfJanuary 01, 2005 - errors by detecting them before harm occurs.6 Our analysis considers both active and latent errors occurring … Active errors include, for example, those occurring at the time of hospital discharge during knowledge … We analyzed the expected and unexpected errors occurring at the hospital discharge using the process … cause analysis is an action plan that identifies the strategies to reduce the risk of similar events occurring
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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.pdfMay 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,… -
www.ahrq.gov/patient-safety/reports/liability/brock.htmlAugust 01, 2017 - instrument does not assess the specific organizational factors that determine how, or if, change is occurring
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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.pdfApril 03, 2008 - reports provided data that confirmed systems mechanisms were in place to prevent actual errors from occurring … interventions to eliminate risk for potential errors and to decrease the possibility of an actual error occurring -
Mod03-Gap-Analysis-Guide (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/mod03-gap-analysis-guide.pdfApril 01, 2016 - Advisory Council Session Preparation The purpose of the focus group sessions is to learn what is occurring … ■ Advise participants that the focus is on learning about what is occurring at the institution as -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014finalhacreport-cx.pdfDecember 01, 2016 - from 2011 to 2014 as a result of the reduction in HACs, with nearly $16 billion of those cost savings occurring
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdfDecember 01, 2016 - from 2011 to 2014 as a result of the reduction in HACs, with nearly $16 billion of those cost savings occurring
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Measure: Appropriateness of Red Cell Transfusions in the Pediatric Intensive Care Unit (PICU) (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/chipra-16-p002-2-ef.pdfMay 01, 2016 - was fairly high, with 91 percent of transfusions meeting the numerator criteria of a transfusion occurring -
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/chipra_1415-p005-2-ef.pdfOctober 01, 2014 - significant costs attributable to a greater need for health care, more frequent unintentional injury, co-occurring
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/chipra_1416-p013-ef.pdfFebruary 01, 2016 - likely to be responsive to changes in health that result from health care interventions or naturally occurring
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www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdfJanuary 01, 2024 - The fault tree is structured with data entry verification occurring after the data entry process and
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptxJanuary 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…
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www.ahrq.gov/patient-safety/settings/hospital/candor/impguide.htmlAugust 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…
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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.docxSeptember 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… -
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.htmlAugust 01, 2022 - Module 6: Care for the Caregiver AHRQ Communication and Optimal Resolution Toolkit Facilitator Notes Say: 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 …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptxMay 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…
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www.ahrq.gov/sites/default/files/2024-01/lipsitz-report.pdfJanuary 01, 2024 - characteristics, and we performed separate analyses of outcomes before the pandemic and while it was still occurring
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Gallagher1.pdfJanuary 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
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