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361. 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 - Staff must be able to document how many falls are occurring in a given time period and why those falls … are occurring.

362. Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_38.pdf
     March 26, 2008 - stage.15 Because administration occurs at the end of the medication use process, with no naturally occurring … documentation of detected/prevented errors, specifically, types of errors; where/when errors were occurring

363. Enabling Real-Time Identification of Burnout Risk Among Clinicians in Primary Care Practices (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/about/impact-stories/enabling-real-time.pdf
     January 01, 2023 - Enabling Real-Time Identification of Burnout Risk Among Clinicians in Primary Care Practices Enabling Real-Time Identification of Burnout Risk Among Clinicians in Primary Care Practices AHRQ Impact: Researchers have developed a prediction tool to identify primary care practices at high-risk of clinician burnout…

364. The Contribution of Diagnostic Error to Maternal Mortality and Severe Maternal Morbidity | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-2.html
     September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science The Contribution of Diagnostic Error to Maternal Mortality and Severe Maternal Morbidity Previous Page Next Page Table of Contents The Contribution of Diagnostic Er…

365. Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
     April 07, 2008 - Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures Stanley Davis, MD; William Riley, PhD; Ayse P. Gurses, PhD; Kr…

366. Making the Case That Improving Antibiotic Use Is a Patient Safety Issue (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/patient-safety-facilitator-guide.pdf
     November 01, 2019 - Making the Case That Improving Antibiotic Use Is a Patient Safety Issue AHRQ Safety Program for Improving Antibiotic Use 1 AHRQ Pub. No. 17(20)-0028-EF November 2019 Making the Case That Improving Antibiotic Use Is a Patient Safety Issue Acute Care Slide Title and Commentary Slide Number…

367. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/objective-outcome-tool.docx
     January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle Hospital ___________ Unit___________ Month ___________ Please record the following occurrences for all patients in your unit within the selected month. ________ Total number of patients on mechanical ventilation ________ Total number of episodes of mechani…

368. FAQs (Staff): Safety and Side Effects: CHG and Mupirocin (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-safety-chg-mupirocin.docx
     March 01, 2022 - FAQs (Staff): Safety and Side Effects: CHG and Mupirocin Decolonization of Non-ICU Patients With Devices Section 14-6 – Addressing Questions Asked by Staff: Safety and Side Effects of Chlorhexidine and Mupirocin This hospital will be using chlorhexidine gluconate (CHG) and nasal mupirocin to reduce bacteria that c…

369. Aspiration Pneumonitis/Pneumonia (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/asp-pneumonitis-one-page.pdf
     November 01, 2019 - Aspiration Pneumonitis/Pneumonia Diagnosis • Aspiration pneumonitis is an abrupt chemical injury caused by inhalation of sterile gastric contents. o It can progress quickly to a decline in respiratory status followed by rapid improvement within 48 hours of the insult. o Chest x rays appear similar to multi…

370. Tool 1: Readmission Data Analysis and Interpretation (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool1_data_analysis_final.xlsx
     June 02, 2025 - Tool 1: Readmission Data Analysis and Interpretation Instructions Tool 1. Readmission Data Analysis and Interpretation Brief Description: A quantitative readmission analysis tool. Purpose: Analyze hospital administrative data to evaluate readmission patterns. Understanding readmission patterns is critical to design…

371. Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
     July 01, 2025 - Quality and Safety Review System (QSRS) Retrospectively Reviewing Inpatient Health Records To Identify Adverse Events Medical errors are an ongoing challenge to the healthcare system in the United States. The extent of medical errors in U.S. hospitals was revealed in 2000 when the Institute of Medicine (now the…

372. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining.html
     November 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training This version of On-Time introduction is for training Facilitators who have not had pressure ulcer prevention training. If they have had that training, this set of slides can be omitted or may be used as a refresher. Slide…

373. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
     August 01, 2022 - System-Focused Event Investigation and Analysis Guide AHRQ Communication and Optimal Resolution Toolkit Purpose : To help teams adopt a system-focused approached to event investigation and analysis. Who should use this tool? Event Reporting, Investigation, and Analysis Team. How to use this tool : Review…

374. 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/pruprev/6.html
     December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Functional Specifications 3. Specifications for Each Pressure Ulcer Prevention Report (continued) 3.6. Risk Change Report (formerly Priority Report) 3.6.1. Report Description The On-Time Risk Change Report (formerly Priority Repo…

375. Sustainability: Learning From Defects: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.html
     December 01, 2017 - Sustainability: Learning From Defects: Slide Presentation AHRQ Safety Program for Surgery Slide 1: AHRQ Safety Program for Surgery—Sustainability Sustainability: Learning From Defects Slide 2: Learning Objectives After this session, you will be able to– Describe the difference between first-orde…

376. Module 3: Script and Slides (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/problem-solving/problem-solving-facnotes.docx
     May 01, 2017 - Module 3: Script and Slides AHRQ Safety Program for Ambulatory Surgery Management Practices for Sustainability Module 3: Problem Solving and Escalation AHRQ Safety Program for Reducing CAUTI in Hospitals Facilitator Notes SLIDE 1 Title: Management Practices for Sustainability, Module 3: Problem Solving and Escalati…

377. Module 3: Problem Solving and Escalation - Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/problem-solving-fac-notes.html
     June 01, 2017 - Module 3: Problem Solving and Escalation - Facilitator Notes Slide 1: Management Practices for Sustainability Module 3: Problem Solving and Escalation Say: In this module, we will focus on two elements in the frontline management system that we have outlined—having well-understood problem-solving and prob…

378. 130-Ss-Swiss-Cheese-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
     April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI Learning From Defects: Applying the “Swiss cheese model” of System Failure Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries Slide Title and Commentary Slide Number and Slide Learning From Defects: Applying the “Swiss C…

379. Chapter 3. Risk-Informed Interventions | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/stpra/stpra3.html
     April 01, 2018 - In addition, ASCs should establish stop-gap measures that prevent surgery from occurring for patients

380. Design Guide for Warm Handoff Plus (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-design-guide-final508.pdf
     June 02, 2025 - Design Guide for Warm Handoff Plus The Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Design Guide for Warm Handoff Plus Introduction In a typical primary care visit, the patient transitions from one member of the healthcare team to another multiple times, often wit…