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  1. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/103-how-to-integrate-cusp-approach-periop-fg.docx
    April 01, 2025 - The purpose of learning from defects is to investigate why systems failed when a defect occurs and to
  2. www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
    November 01, 2021 - NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency NPSD Data Spotlight This document is in the public domain and may b…
  3. www.ahrq.gov/sites/default/files/2024-02/mackenzie-report.pdf
    January 01, 2024 - Conceptual framework guides observation, but data parsing occurs at the time of observation, not after
  4. www.ahrq.gov/sites/default/files/2024-12/morgan-report.pdf
    January 01, 2024 - Being colonized with bacteria requiring contact isolation occurs primarily in the medically complex
  5. www.ahrq.gov/hai/tools/mvp/modules/technical/daily-early-mobility-fac-guide.html
    February 01, 2017 - Measure Descriptions for Daily Early Mobility: Facilitator Guide AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: Measure Descriptions for Daily Early Mobility Say: In this module, you will learn about the data measures you will use to evaluate early mobility process and outcome measure…
  6. www.ahrq.gov/sites/default/files/2024-12/weinger2-report.pdf
    January 01, 2024 - non-routine event approach for the early detection of risks to patient safety before serious patient harm occurs
  7. www.ahrq.gov/sites/default/files/2024-09/ratwani-report.pdf
    January 01, 2024 - Final Progress Report: Developing and Training Interruption Management Strategies for Emergency Physicians 1. TITLE PAGE Title: Developing and Training Interruption Management Strategies for Emergency Physicians Principal Investigator: Raj M. Ratwani, PhD Co-investigators: Zach Hettinger, MD, MS; Allan Fong, MS; T…
  8. www.ahrq.gov/research/findings/final-reports/diabetesnetwork/diabnet3.html
    October 01, 2014 - Hispanic Diabetes Disparities Learning Network in Community Health Centers Chapter 3. Structure of Learning Network Previous Page Next Page Table of Contents Hispanic Diabetes Disparities Learning Network in Community Health Centers Chapter 1. Introduction Chapter 2. Project Description Chapte…
  9. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/guide.html
    December 01, 2017 - It also asks which staff members are invited, who leads the meeting, and how often it occurs. … Investigate root causes when an adverse event occurs.
  10. 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 - conscientious, and vigilant personnel, and by seeking to repair damage honestly and respectfully when it occurs … That is, the immediate environment in which care occurs—the operating room, the emergency department … identification (probably excessively so) of patient safety with RCA is a result of heightened attention that occurs
  11. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/reports.html
    November 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Electronic Reports Four types of reports are described here. Each section presents a sample report followed by purpose, description, and users and potential uses. The types of reports are: On-Time Falls High-Risk Report . Quarterly Summar…
  12. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014finalhacreport-cx.pdf
    December 01, 2016 - Interim Update on 2013 Annual Hospital-Acquired Condition Rate December 2016 Saving Lives and Saving Money: Hospital-Acquired Conditions Update Final Data From National Efforts To Make Care Safer, 2010-2014 Summary Final estimates for 2014 show a sustained 17 percent decline in hospital-acquired conditions…
  13. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
    December 01, 2016 - Final Data From National Efforts To Make Care Safer, 2010-2014 December 2016 Saving Lives and Saving Money: Hospital-Acquired Conditions Update Final Data From National Efforts To Make Care Safer, 2010-2014 Summary Final estimates for 2014 show a sustained 17 percent decline in hospital-acquired conditions…
  14. www.ahrq.gov/sites/default/files/2024-09/czeisler-report.pdf
    January 01, 2024 - Final Progress Report: Effects of Extended Work Hours on ICU Patient Safety Final Progress Report Title: Effects of Extended Work Hours on ICU Patient Safety Principal Investigator: Charles A. Czeisler, Ph.D., M.D. Organization: Brigham and Women's Hospital Co-Investigators: Christopher P. Landrigan, M.D., M.P.H.…
  15. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.pdf
    June 02, 2025 - It also asks which staff members are invited, who leads the meeting, and how often it occurs. … plans;  Discuss care changes that are needed; and  Investigate root causes when an adverse event occurs
  16. www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter5.html
    August 01, 2022 - first stage is initiated when a health care consumer who has experienced a patient safety event (which occurs
  17. Data Measures Guide (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/datameasures-guide.pdf
    January 01, 2017 - Data Measures Guide AHRQ Safety Program for Mechanically Ventilated Patients Data Measures Guide AHRQ Pub. No. 16(17)-0018-6-EF January 2017 Data Measures Guide Introduction ....................................................................................................................…
  18. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-casereport.pdf
    September 05, 2017 -  What happens if a problem occurs? o Where does the process typically occur? … • o How much, if any, down time occurs? …  What happens if a problem occurs? o Where does the process typically occur? … • o How much, if any, down time occurs?
  19. www.ahrq.gov/prevention/resources/vision/resources/vision2.html
    October 01, 2002 - Destruction of the retinal nerve occurs when fluid leaks into the choroid and forms scar tissue. … remains to be substantiated with evidence. 42 Entry into the system for vision rehabilitation often occurs
  20. www.ahrq.gov/research/shuttered/toolkitchecklist/surgetkit2.html
    July 01, 2018 - Timeframe: As soon as the catastrophic event occurs, planned arrangements for the surge facility should … Timeframe: As soon as the catastrophic event occurs, planned arrangements for the surge facility should

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