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www.ahrq.gov/sites/default/files/2024-12/cook-hoas-report.pdf
January 01, 2024 - Final Progress Report: Quality Care and Error Reduction in Rural Hospitals
Principal Investigator: Cook, Ann F.
Title of the Project: Quality Care and Error Reduction in Rural Hospitals
Principal Investigator: Ann Cook, Ph.D.
Co-investigator: Helena Hoas, Ph.D.
Team Member: Katarina Guttmannova, Ph.D.
Organizat…
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www.ahrq.gov/sites/default/files/2024-01/gurwitz-report.pdf
January 01, 2024 - Final Progress Report: Enhancing the Safety of Warfarin in the Nursing Home
Project Title: Enhancing the Safety of Warfarin in the Nursing Home
Principal Investigator: Jerry H. Gurwitz, MD
Principal Team Members: Jerry Gurwitz, MD; Terry S. Field, DSc; Jennifer Tjia, MD,
MSCE; Kathleen M. Mazor, EdD; Leslie R. Ha…
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www.ahrq.gov/sites/default/files/2024-01/guise2-report.pdf
January 01, 2024 - Final Grant Report: Using Military & Aviation Simulation Experience to Improve Rural Obstetric Safety
PI: Guise, J-M
FINAL GRANT REPORT
Title: Using Military & Aviation Simulation Experience to Improve Rural Obstetric Safety
Grant Award #: 5U18HS015800-02
Grantee Institution: Oregon Health & Science University…
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www.ahrq.gov/sites/default/files/2024-02/zierler-report.pdf
January 01, 2024 - Final Progress Report: VTE Safety Toolkit: A Systems Approach to Patient Safety
Title: VTE Safety Toolkit: A Systems Approach to Patient Safety
Principal Investigator: Brenda K. Zierler, PhD1
Team Members:
Ann Wittkowsky, PharmD2
Robb Glenny, MD3
Seth Wolpin, PhD1
Jung-Ah Lee, MN1
Gene Peterson, MD, PhD3
Fre…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-150-fullreport.pdf
February 14, 2018 - Metabolic Monitoring for Children and Adolescents on Antipsychotics
1
Metabolic Monitoring for Children and Adolescents
on Antipsychotics
Section 1. Basic Measure Information
1.A. Measure Name
Metabolic Monitoring for Children and Adolescents on Antipsychotics
1.B. Measure Number
0150
1.C. Measure Descripti…
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www.ahrq.gov/sites/default/files/2024-04/dykes-report.pdf
January 01, 2024 - Final Progress Report: Generalizability and Spread of an Evidenced-based Fall Prevention Toolkit: Fall TIPS
Project Title: Generalizability and Spread of an Evidenced-based Fall Prevention Toolkit: Fall TIPS
(Tailoring Interventions for Patient Safety)
Principal Investigator and Team Members.
Patricia C. Dykes, An…
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www.ahrq.gov/sites/default/files/publications2/files/takeheart-hybrid-workgroup-evaluation.pdf
August 01, 2023 - Implementing PCOR To Increase Referral, Enrollment, and Retention in Cardiac Rehabilitation Through Automatic Referral With Care Coordination
e
Implementing PCOR To Increase Referral,
Enrollment, and Retention in Cardiac
Rehabilitation through Automatic Referral
with Care Coordination
Hybrid CR Workgroup
Evalu…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/004-ss-antimicrobial-prophylaxis-part-2.pptx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
AHRQ Safety Program for MRSA Prevention: Targeting SSI
Antimicrobial Perioperative Prophylaxis: Part 2
Beyond the Basics
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
AHRQ Pub. No. 25-0029
April 2025
AHRQ Safety Pro…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
January 01, 2004 - Diagnostic Failure: A Cognitive and Affective Approach
241
Diagnostic Failure: A Cognitive
and Affective Approach
Pat Croskerry
Abstract
Diagnosis is the foundation of medicine. Effective treatment cannot begin until an
accurate diagnosis has been made. Diagnostic reasoning is a critical aspect of
clinic…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
April 22, 2004 - Work System Analysis: The Key to Understanding Health Care Systems
337
Work System Analysis: The Key to
Understanding Health Care Systems
Ben-Tzion Karsh, Samuel J. Alper
Abstract
Many articles in the medical literature state that medical errors are the result of
systems problems, require systems analyses, a…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Wideman.pdf
April 20, 2004 - Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation
437
Barcode Medication Administration:
Lessons Learned from an Intensive
Care Unit Implementation
Mary V. Wideman, Michael E. Whittler, Timothy M. Anderson
Abstract
An electronic barcode medication administration sy…
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/adult-eng-cg40-3351a.pdf
October 30, 2020 - CAHPS Clinician & Group Adult Visit Survey 4.0 (beta)
CAHPS Clinician & Group Survey
Version: Adult Visit Survey 4.0 (beta)
Language: English
Notes
• Purpose of Visit Survey 4.0 (beta): This new version of the Clinician & Group Survey
asks patients about their experiences with care at their most recent visit…
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-166-fullreport.pdf
March 01, 2018 - Family Experiences with Coordination of Care (FECC) Measure Set
1
Family Experiences with Coordination of Care (FECC)
Measure Set
Section 1. Basic Measure Information
1.A. Measure Name
Family Experiences with Coordination of Care (FECC) Measure Set
1.B. Measure Number
0166 FECC Survey/Measure Set
1.C. Measu…
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0217-fullreport.pdf
April 01, 2018 - Appropriate Emergency Department Pain Assessment for Children With Sickle Cell Disease
1
Appropriate Emergency Department Pain Assessment
for Children with Sickle Cell Disease
Section 1. Basic Measure Information
1.A. Measure Name
Appropriate Emergency Department Pain Assessment for Children with Sickle Cell D…
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-216-fullreport.pdf
February 01, 2018 - Appropriate Emergency Department Fever Management for Children With Sickle Cell Disease
1
Appropriate Emergency Department Fever
Management for Children with Sickle Cell Disease
Section 1. Basic Measure Information
1.A. Measure Name
Appropriate Emergency Department Fever Management for Children with Sickle Cel…
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/child-eng-cg30-2353a.pdf
August 01, 2015 - CAHPS Clinician & Group Child Survey 3.0
CAHPS® Clinician & Group Survey
Version: 3.0
Population: Child
Language: English
Notes
• References to “this provider” rather than “this doctor:” This survey uses “this provider”
to refer to the individual specifically named in Question 1. A “provider” could be a do…
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/workflow-analysis-qi.pdf
February 01, 2005 - Workflow
Workflow
Ann Lefebvre MSW, CPHQ
Associate Director, NC AHEC
North Carolina Area Health Education Centers
North Carolina Area Health Education Centers
“Every system is perfectly designed to get the
results that it gets.”
Paul Batalden, MD
North Carolina Area Health Education CentersNorth Carolina…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/AHRQ-Hospital-Survey-2.0-Users-Guide-5.26.2021.pdf
January 01, 2021 - • Exclude staff who no longer work at the hospital;
• Exclude staff who only work in outpatient offices
-
www.ahrq.gov/patient-safety/settings/hospital/candor/acknowledgements.html
August 01, 2022 - Acknowledgments
AHRQ Communication and Optimal Resolution Toolkit
The Communication and Optimal Resolution (CANDOR) process was funded by AHRQ and is based on input from experts, key stakeholders, and lessons learned from the agency's $25 million Patient Safety and Medical Liability (PSML) Grant Initiative la…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-casereport.pdf
September 05, 2017 - Issues and initiatives in the
testing process in primary care physician offices.