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3401. Final Progress Report: Staff Nurse Fatigue and Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-09/rogers-report.pdf
      January 01, 2024 - Final Progress Report: Staff Nurse Fatigue and Patient Safety Staff Nurse Fatigue and Patient Safety … Caucasian 78.7% 86.7% Hispanic 1.5% 1.2% Hawaiian/Pacific Islander 0.5% 0.2% Mean years experience … data-gathering period or to determine if the errors reported by study participants actually harmed patients … In Page, A (editor) Keeping patients safe: Transforming the work of nurses Washington, D.C.: National … Fatigue among clinicians and the safety of patients. NEJM.

3402. Standardizing Medication Error Event Reporting in the U.S. Department of Defense (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
      March 01, 2004 - Of the actual events, 26 percent involved female patients, 22 percent involved male patients, and 52 … Of the reported events that reached the patient, 18 percent occurred in patients ages 5 years or younger … , 6 percent occurred in patients between the ages of 6 and 17 years, and 24 percent occurred in patients … patients 5 years of age or younger, 6 percent of the errors occurred in patients between 6 and 17 … occurred in patients 65 years of age and older.

3403. Documentation and Coding for the AHRQ Pediatric Quality Indicators (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/b4_pdi_documentationcoding.pdf
      March 15, 2016 - • Review all deaths (e.g., patients who died with a low risk of mortality) to uncover improvement … Another would be to audit charts to find missed cases, especially those of high-risk patients (e.g., … length of stay, ICU populations who may be at risk for pressure ulcers or CLABSI, deaths, oncology patients … Impact of date stamping on patient safety measurements in patients undergoing CABG: experience with … AHRQ Patient Safety Indicators.

3404. Webinar Transcript - The 2014 Quality and Disparities Report and the National Quality Strategy: Working Together to Improve Health Care | Agency for Healthcare Research and Quality
      www.ahrq.gov/workingforquality/events/webinar-2014-qdr-working-together-to-improve-health-care.html
      November 01, 2016 - for Patients campaign and we have that information in the chart book. … safety, that minorities and low income people typically experience more patient safety issues when they … Home health patients with improvement in surgical wounds, by age and race/ethnicity, 2010-2012 [Slide … that where we've put our attention is where we've gotten improvement so, you know, the Partnership for Patients … Part of the history of this issue has been the primary care docs have not been accessible for patients

3405. Final Topic Refinement Document - Role of Liquid Biopsy in Detection and Management of Cancer in the Medicare Population (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/liquid-biopsy-topicrefinement.pdf
      July 29, 2021 - clinicians, relevant professional and consumer organizations, purchasers of health care, and others with experience … Is the Patient Cured? JAMA Oncol. 2019 Oct 17. … (Singal G Association of patient characteristics and tumor genomics with clinical outcomes among patients … Clinical Genomics has extensive experience in the field of liquid biopsy for the detection and management … the important work on “liquid biopsy” that AHRQ is considering can be aided by Natera’s analysis and experience

3406. Close-Out Report: Improving Resuscitation Team Response to Inpatient Critical Events by Simulation (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/pliego-report.pdf
      January 01, 2024 - is to decrease mortality rates in non-expectant (non-Do Not Resuscitate), non-intensive care unit patients … patients in our tertiary care inpatient hospital. 2. … was a 35-year-old, male, non-DNR motorcycle accident patient, who became unconscious). … safety and then rectified those errors to improve patient safety. … Awarded 3rd Place in Patient Safety Research Projects 4.

3407. 43-Pathway-Worksheet (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/43-pathway-worksheet.docx
      June 01, 2023 - All ISCR Pathways Patient Education Recommended approach: Review existing patient education materials … for surgery patients Adapt the provided patient education booklet template as needed to your hospital … Patient education provided to patient/caregiver Example: Providing ISCR patient education booklet and … at increased risk of adverse outcomes and often experience delayed and dampened functional recovery. … unless they experience nausea or vomiting.

3408. Severe Hypertension Scenarios: PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/sppcii-hypertension-scenarios.pptx
      July 01, 2023 - Notice where clinician interactions are crucial to keeping patients safe. … case, you may see places where clinicians could provide more and better interactions to keep their patients … 16 Yes, a vaginal delivery is completely possible so long as we don’t experience any additional complications … The treatment team can consider other options for obtaining IV access in difficult patients. … can feel that they can speak freely, it is wise to talk with your patients about how they perceived

3409. TeamSTEPPS Building Block Exercise Instructions (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-exercise-instructions.pdf
      June 02, 2025 - group needs a Facilitator you have trained in advance; they need to understand the exercise and have experience … Instructions 7 Teamwork Exercise: Conclusions Conclusions: • All complex activities (especially patient … Use Round 3 to call attention to the challenges facing patients or family caregivers who may not share

3410. Final Progress Report: What Is Patient Safety in the Medical Home? (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/dy-report.pdf
      January 01, 2024 - Frontline personnel and patients conceptualized patient safety in largely consistent ways, with some … Strategies included expanding the focused search for patient information by visiting patients’ homes … clinicians, administrators, staff, and patients underscored the importance of the patient perspective … Strategies included expanding the focused search for patient information by visiting patients’ homes … Patient safety in primary care: Conceptual meanings to the health care team and patients.

3411. Observing Nurse Interaction with Infusion Pump Technologies (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Carayon.pdf
      January 01, 2004 - or patient were never recorded. … Patients’ rooms were observed to be more often quiet than the medication room. … room Medication room Patient room Medication room Patient room Lighting • full • dimmed … Patients’ rooms tended to be more quiet than the medication room. … Patients’ rooms were found to be loud in six instances.

3412. Session 1 | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess3.html
      October 01, 2014 - Assessing patients after a fall to identify and treat their risk factors for the future. … Key Facts About Patient Safety. Boston, MA: National Patient Safety Foundation; 1997. … Available at http://www.npsf.org/for-patients-consumers/patients-and-consumers-key-facts-about-patient-safety … The patient who falls. JAMA 2010; 303(3):258-266. 8.

3413. Final Progress Report: Reducing Diagnostic Errors in Primary Care Pediatrics (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/rinke-report.pdf
      January 01, 2025 - These mini root cause analyses examined a patient with a BP error in their clinic and 15 standardized … For each eligible patient, practices recorded age, sex, and insurance status (public, private, self, … By focusing on just one error at a time, practices would also likely experience less data collection … Patient safety strategies targeted at diagnostic errors: a systematic review. … Social disparities in patient safety in primary care: a systematic review.

3414. Managing Interruptions to Improve Diagnostic Decision-Making: Strategies and Recommended Research Agenda (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/managing-interruptions-improve-diagnostic-decisionmaking.pdf
      December 29, 2022 - clinicians better manage interruptions has the potential to minimize diagnostic errors and improve patient … Although EHRs can provide easier access to patient data and timeliness of documentation, EHRs may also … For example, the dynamic, fast-paced environ- ment with high-acuity patients being taken care of by multiple … Disrupting diagnostic reasoning: do interruptions, instructions, and experience affect the diagnostic … J Patient Saf 2010;6(2):121. 23. Falkland EC, Wiggins MW, Douglas H, et al.

3415. Coaching Clinical Teams Module: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/coaching-fac-notes.html
      October 01, 2020 - Studies have shown that coaching can lead to better patient care. … "How did you experience that?" "I wonder what you think happened?" … Instead say: “I saw your team didn’t review the specimen labeling before the patient left the room. … Coaching should never interfere with direct patient care. … Coaching can help ensure improvements in patient care become a standard of practice for every patient

3416. Coaching-Facnotes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/coaching/coaching-facnotes.docx
      May 01, 2017 - Studies have shown that coaching can lead to better patient care. … · “How did you experience that?” · “I wonder what you think happened?” … Instead say: “I saw your team didn’t review the specimen labeling before the patient left the room. … Coaching should never interfere with direct patient care. … Coaching can help ensure improvements in patient care become a standard of practice for every patient

3417. Module 15: Preparing and Presenting Performance Data (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-15-presenting-data.pdf
      September 01, 2015 - What experience have you had in the past collecting and presenting performance data to an organization … It served 35,000 patients and provided approximately 80,000 patient visits last year. … The organization wants to improve patient experience and is interested in reducing patient cycle time … Forty-five percent of patients are children, 50 percent of patients are adults, and 5 percent are geriatric … Patient list generator Step 1: Identify all patients that meet all of the following criteria:

3418. Collecting Performance Data Using Chart Audits and Electronic Data Extraction (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-14-collecting-performance-data.pdf
      September 01, 2015 - What experience have you had conducting paper chart audits or working with electronic systems to collect … the past 12 months) • Patient exclusion criteria (for example, patients with ESRD) • Time period covered … It served 35,000 patients and provided approximately 80,000 patient visits last year. … The organization wants to improve patient experience and is interested in reducing patient cycle time … Patient list generator Step 1: Identify all patients that meet all of the following criteria:

3419. Frequently Asked Questions - RFA-HS-24-004: State-based Healthcare Extension Cooperatives to Accelerate Implementation of Actionable Knowledge into Practice (U19) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/funding/fund-opps/RFA-HS-24-004-faq-112524.pdf
      November 25, 2024 - that include clinician- or practice-facing measures or do interventions or outcomes need to focus on patients … or professional research associate could serve in this role, provided that they have the skills and experience … The initiative must be based on patient-centered healthcare delivery improvements, with the definition … with Brownson and colleagues, evidence-based, patient-centered, healthcare delivery https://gcc02. … policies with some evidence of effectiveness in improving health outcomes that are meaningful for patients

3420. Acute Care Behavior Change Theory for Antibiotic Stewardship Leaders
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/behavior-change-slides.pptx
      November 01, 2019 - 6 Drivers of Suboptimal Antibiotic Prescribing Fear of inadequate antibiotic coverage leading to patient … 7 Drivers of Suboptimal Antibiotic Prescribing Fear of inadequate antibiotic coverage leading to patient … who were harmed Evidence that the individual patient can be harmed Discuss with senior executive 16 … After Therapy can be stopped after the patient is: Afebrile for 48–72 hours and Has no more than one … specific factors: 5 days: Patient without immunocompromise or structural lung disease 7 days: Patients