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3241. Primary Care Visual Error Reporting Tool- Part 2 (pdf file)
      digital.ahrq.gov/sites/default/files/docs/resource/b4_singh_017020_archives_17_part2.pdf
      January 01, 2009 - Primary Care Visual Error Reporting Tool- Part 2 1/2 In an effort to bring some standardization and efficiency to the chart-review process, a two-step method is used. As the first step, a set of screening criteria identifying the presence of ce…

3242. Process Mapping | Digital Healthcare Research
      digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/process-0
      January 01, 2023 - Process Mapping Use Case Description A use case is a set of instructions that an individual in a process completes to go through one single step in that process. It describes what the user does to interact with a system. Value Stream Mapping Descr…

3243. Fault Tree Analysis | Digital Healthcare Research
      digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/fault-tree-analysis
      January 01, 2023 - Fault Tree Analysis Acronym FTA Description Fault tree analyses (FTAs) study specific system, process, or product failures using a tree diagram . The process can be used to study a failure that actually occurred, or it could study a potential failure. The technique starts with the failure an…

3244. Module 3: Falls Prevention and Management | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3.html
      March 01, 2019 - Module 3: Falls Prevention and Management Next Page Table of Contents Module 3: Falls Prevention and Management Learning and Performance Objectives Session 1 Session 2 Conclusion Appendix. Additional Tools and Resources Improving Patient Safety in Long-Term Care Facilities …

3245. Wrong site surgery: a critical incident analysis of a near miss. | PSNet
      psnet.ahrq.gov/issue/wrong-site-surgery-critical-incident-analysis-near-miss
      June 15, 2024 - Commentary Wrong site surgery: a critical incident analysis of a near miss. Citation Text: Tichanow S. Wrong site surgery: A critical incident analysis of a near miss. J Perioper Pract. 2016;26(1-2):11-5. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML End…

3246. 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/impmenu.html
      January 01, 2015 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Implementation Materials: Menu of Implementation Strategies Three implementation documents are used to help the nursing home change team integrate the pressure ulcer prevention reports they choose to use into day-to-day clinical decisi…

3247. When medical students make errors. | PSNet
      psnet.ahrq.gov/issue/when-medical-students-make-errors
      March 08, 2017 - Newspaper/Magazine Article When medical students make errors. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 28, 2014 View more articles from the same authors. This newspa…

3248. Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. | PSNet
      psnet.ahrq.gov/issue/sentinel-event-alert-67-preserving-patient-safety-after-cyberattack
      March 13, 2024 - Sentinel Event Alerts Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. Citation Text: Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. Jt Comm J Qual Patient Saf. 2023;49(12):724-729. doi:10.1016/j.jcjq.2023.07.006. Copy Citation Format…

3249. 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/assess.html
      November 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Falls Prevention Self-Assessment Worksheet Purpose The Self-Assessment Worksheet is a worksheet designed to help staff review how they currently identify residents who have experienced a change in falls risk, how they determine if new clinica…

3250. Effective Health Care (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/TND_0215_01-06-2010.pdf
      January 01, 2010 - Effective Health Care Topic Number(s): 0239 Document Completion Date: 8-13-10 1 Results of Topic Selection Process & Next Steps  Treatment of restless legs syndrome will go forward for refinement as a systematic review. The scope of this topic, including populations, interventions, comparato…

3251. Patient/Family Crisis Hotline. | PSNet
      psnet.ahrq.gov/issue/patientfamily-crisis-hotline
      December 02, 2020 - Multi-use Website Patient/Family Crisis Hotline. Citation Text: Patient/Family Crisis Hotline. Sorry Works!  Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …

3252. TeamSTEPPS® Diagnosis Improvement: Infographic (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-infographic.pdf
      February 01, 2022 - TeamSTEPPS® Diagnosis Improvement: Infographic TeamSTEPPS® for Diagnosis Improvement AHRQ Publication No. 22-0015 February 2022 References 1. National Academies of Sciences, Engineering, and Medicine. Improving Diagnosis in Health Care. Washington, DC: National Academies Press; 2015. https://doi.org/10.17226/21…

3253. 041-Pros-Cons-Mrsa-Surveillance-One-Pager (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/041-pros-cons-mrsa-surveillance-one-pager.docx
      October 01, 2024 - To protect patients from methicillin-resistant Staphylococcus aureus (MRSA) infections and develop effective MRSA prevention strategies, facilities must know the MRSA prevalence among their specific patient population and understand when and where transmission occurs. MRSA surveillance provides this type of insight. MR…

3254. Supplemental Items for the CAHPS Clinician & Group Adult Survey 3.0: Shared Decisionmaking | Agency for Healthcare Research and Quality
      www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-decisionmaking-cg30-adult.html
      November 01, 2017 - Supplemental Items for the CAHPS Clinician & Group Adult Survey 3.0: Shared Decisionmaking Population version: Adult Download these items: English (Word, 29 KB) Users of the CAHPS Clinician & Group Survey are free to incorporate supplemental items in order to meet the needs of their organizations, local…

3255. Make safety a priority: create and maintain a culture of safety. | PSNet
      psnet.ahrq.gov/issue/make-safety-priority-create-and-maintain-culture-safety
      February 25, 2013 - Newspaper/Magazine Article Make safety a priority: create and maintain a culture of safety. Citation Text: Make safety a priority: create and maintain a culture of safety. Leonard M; Frankel A. Copy Citation Save Save to your library Print Download P…

3256. Introduction | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-1.html
      March 01, 2022 - Improving Education—A Key to Better Diagnostic Outcomes Introduction Previous Page Next Page Table of Contents Improving Education—A Key to Better Diagnostic Outcomes Introduction Foundations of Diagnosis Education Current State of Diagnosis Education Competencies To Improve Diagnosis in Hea…

3257. NICU Family Information Packet, Appendix B, Apnea Of Prematurity (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-apnea.pdf
      June 02, 2025 - NICU Family Information Packet, Appendix B, Apnea Of Prematurity Apnea Of Prematurity Characteristics ■ Respiratory pause for at least 20 seconds, or a pause that is accompanied by bradycardia (heart rate <100 bpm), cyanosis, or pallor in an infant <37 weeks postmenstrual age (PMA). ■ Types of apnea: – Central…

3258. NICU Family Information Packet, Appendix B, Vision Screening and Retinopathy (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-vision.pdf
      June 02, 2025 - NICU Family Information Packet, Appendix B, Vision Screening and Retinopathy Vision Screening and Retinopathy of Prematurity Visual Deficits Seen in Preterm Infants ■ High-risk infants are more likely to have permanent visual deficits and/or show a delay in visual development that persists until adolescence. ■ …

3259. Dear [NURSES NAMES]-- (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/clabsitools/clabsitoolsap9.doc
      June 02, 2025 - Dear [NURSES NAMES]-- CLABSI Investigation Nurse Letter (Date) Dear ____________, As part of our commitment to eradicate central line-associated blood stream infections (CLABSIs), we are performing a root cause analysis of all CLABSIs. Patient _______________ met the U.S. Centers for Disease Control and Prevention c…

3260. Dear [NURSES NAMES]-- (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/clabsitools/clabsitoolsap8.doc
      June 02, 2025 - Dear [NURSES NAMES]-- CLABSI Investigation Nurse Letter (Date) Dear ____________, As part of our commitment to eradicate central line-associated blood stream infections (CLABSIs), we are performing a root cause analysis of all CLABSIs. Patient _______________ met the U.S. Centers for Disease Control and Prevention c…