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401. Exhibit 4.2. Suntown Hospital | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-2.html
     November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 4.2. Suntown Hospital Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Healthcare Case 2. Central Hospital Ca…

402. What Exactly Is Patient Safety? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf
     July 02, 2008 - First, medical injury was acknowledged as occurring far more often than heretofore realized, with most

403. The Science of Improving Patient Safety and Identifying Defects: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
     December 01, 2017 - defects that the team can address, and helps teams design interventions that prevent the defects from occurring

404. 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/care/resources/ontime/pruprev/saworksheet.html
     December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Self-Assessment Worksheet for Pressure Ulcer Prevention The Self-Assessment Worksheet is designed to help staff review how they currently identify residents who have experienced a change in pressure ulcer risk, how they determine if ne…

405. 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…

406. 1 Preventablehospitaledvisits-Overview-Ig (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/1_preventablehospitaledvisits-overview-ig.pdf
     June 02, 2025 - Overview Slide AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Facilitator Training: Overview of On-Time This version of the On-Time Facilitator Training Overview is for training Facilitators who have not had pressure ulcer prevention training. If they h…

407. Saworksheet (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/saworksheet.docx
     June 02, 2025 - On-Time Pressure Ulcer Prevention Self-Assessment Worksheet for Pressure Ulcer The Self-Assessment Worksheet is designed to help staff review how they currently identify residents who have experienced a change in pressure ulcer risk, how they determine if new clinical interventions are needed, and how they determine w…

408. TeamSTEPPS Team Leadership Module 2
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-module-2-slides.pptx
     June 02, 2025 - TeamSTEPPS Team Leadership Module 2 Team Leadership Module 2 1 Understanding Teams and Team Structure 2 Objectives: Team Structure Team Leadership Understand the benefits of teamwork and clear team structure. Define a “team.” Identify the roles of patients and family caregivers within the care team. Desc…

409. Final Progress Report: Prescribing Errors in Ambulatory Pediatric Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/basco-report.pdf
     January 01, 2024 - dosing errors in 15% of outpatient prescriptions. (7) Choice of incorrect drug is also a common error, occurring … frequencies of "screening alerts" that a pharmacist might experience if screening for LASA errors were occurring

410. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
     January 01, 2004 - relating to medication errors Medication related errors are one of the most common types of errors occurring … in hospitals, occurring throughout the medication process from prescription to administration.

411. 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/learn-from-defects-facguide.docx
     January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle Slide Title and Commentary Slide Number and Slide Title Slide Learning From Defects in Care of Mechanically Ventilated Patients SAY: In this module, we will discuss the Learning From Defects tool. It is a very useful process that enables frontline staff to ident…

412. CommonSpirit Health Expands CANDOR Toolkit Across Entire Health System | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/202104.html
     October 01, 2021 - CommonSpirit Health Expands CANDOR Toolkit Across Entire Health System Search All Impact Case Studies October 2021 CommonSpirit Health, one of the Nation's largest health systems, serving 21 States, is expanding its use of AHRQ's  Communication and Optimal Resolution (CANDOR) toolkit  across its entire netw…

413. Describe How a Plan or Provider Can Influence a Quality Measure | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/translate/labels/describe.html
     January 01, 2023 - Describe How a Plan or Provider Can Influence a Quality Measure For some measures, it may be necessary to explain what the plan or provider can do to improve its performance. Providers are often concerned that they are being rated on measures over which they believe they have limited influence. When the public …

414. Four Moments of Antibiotic Decision Making | Agency for Healthcare Research and Quality
     www.ahrq.gov/antibiotic-use/acute-care/four-moments/index.html
     November 01, 2019 - Four Moments of Antibiotic Decision Making The Four Moments of Antibiotic Decision Making are the critical time periods of antibiotic decision making. Clinicians are encouraged to use the Four Moments framework for all patients receiving antibiotics and whenever the need for antibiotics is being considered. …

415. 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…

416. Strategy 6P: Service Recovery Programs | Agency for Healthcare Research and Quality
     www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/customer-service/strategy6p-service-recovery.html
     April 01, 2022 - Be proactive, not reactive; try to anticipate negative situations from occurring in the first place.

417. Antibiotic-Patient-Safety-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-patient-safety-facilitator-guide.docx
     June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use 1 Improving Antibiotic Use Is a Patient Safety Issue Long-Term Care Slide Title and Commentary Slide Number and Slide Improving Antibiotic Use Is a Patient Safety Issue Long-Term Care SAY: Welcome to this presentation titled “Improving Antibiotic Use Is a Patie…

418. Designing Consumer Reporting Systems for Patient Safety Events: Final Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/consumer-experience/reporting/11-0060-EF.pdf
     May 01, 2011 - Reporting systems will need to be flexible regarding analysis and other activities occurring at local … goals for consumer reporting systems. 27 flexible regarding analysis and other activities occurring … As such, consumers may be able to provide much more information on events occurring during transitions … vigilant health care professionals and systems will attempt to both prevent patient safety events from occurring

419. Designing Consumer Reporting Systems for Patient Safety Events: Final Report (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/11-0060-EF.pdf
     May 01, 2011 - Reporting systems will need to be flexible regarding analysis and other activities occurring at local … goals for consumer reporting systems. 27 flexible regarding analysis and other activities occurring … As such, consumers may be able to provide much more information on events occurring during transitions … vigilant health care professionals and systems will attempt to both prevent patient safety events from occurring

420. NICU Family Information Packet, Appendix B, Tracheostomies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-trache.pdf
     June 02, 2025 - NICU Family Information Packet, Appendix B, Tracheostomies Tracheostomies Tracheostomy Basics ■ Indications: upper airway obstruction, long term ventilation, ease of pulmonary toilet, to protect the airway. ■ Tube selection based on: – Indication for tracheostomy. – Tracheal width/length/shape. – Upper a…