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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2025-nursing-home-workplace-safety-report-pt1.pdf
January 01, 2025 - Patient Safety Culture® (SOPS®)
Workplace Safety Supplemental Items for
Nursing Homes: 2025 Updated … Surveys on Patient Safety Culture® and SOPS® are registered trademarks of the U.S. … Surveys on Patient Safety
Culture® (SOPS®) Workplace Safety Supplemental Items for Nursing Homes: 2025 … Action planning for patient safety improvement
The Action Planning Tool for the AHRQ Surveys on Patient … Action planning for patient safety improvement
2.
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/building-capacity/en-bsc-final-report-b.pdf
January 01, 2025 - Overall, nearly half were safety net practices (43%). … specific major disruptive events: As an additional sensitivity analysis, we
examined models containing indicators … • Create panels of patients.
• Identify needed services for patients. … • Link patients with community resources. … Practices’ Patient Population Characteristics
3.1.3.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/webinar02/spc_slides.pptx
June 04, 2013 - Statistical Process Control--
Possible Uses to Monitor and Evaluate Patient-Centered Medical Home Models … Safety and Quality, Johns Hopkins Medicine
With Thanks to Mimi Huizinga, MD, Melissa Sherry, MPH … Identify differences across groups
Aid self-management interventions
Monitor changes in individual patients … that analyzes data from electronic medical records to continuously monitor for abnormal patterns in patients … Application of this approach can be at the patient, provider and population levels.
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www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide6.html
May 01, 2016 - The outcome (whether a patient develops an HA-VTE) is linked to use of the order set, whether the patient … No, patient was under-prophylaxed, OR No, patient was over-prophylaxed. … Patients hospitalized less than 48 hours.
Patients <18 years of age.
Comfort care patients. … Stratified random sampling: Patients from several important patient groups are randomly sampled (e.g … AHRQ's Quality Indicators include a Patient Safety Indicator (AHRQ PSI #12) that does not use the POA
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - Most non-ICU patients on telemetry are hemodynamically stable, whereas those in ICU may not be. … units, in addition to providing care to their own critically ill patients. … (Consideration of the patient safety issues related to frequency of patient assessment in the hospital … Education, Quality, and Safety Measures
What are predefined patient safety and quality outcomes … safety.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
December 23, 2004 - The facility had a problem with preventive maintenance of its
Advances in Patient Safety: Vol. 2 … addressing the patients’ needs). … As in the Eindhoven taxonomy, slips
Advances in Patient Safety: Vol. 2
80
Figure 1. … A
Advances in Patient Safety: Vol. 2
82
Figure 3. … Advances in Patient Safety: Vol. 2
86
Author affiliations
Departments of Medical Physics, Human
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
April 07, 2008 - Joint Comisssion perspectives on patient safety. Using
FMEA to assess risk and reduce error. … Advances in
patient safety: From research to implementation. … Incidence of
adverse events and negligence in hospitalized patients. … Organizing patient safety
research to identify risks and hazards. … Sensemaking
of patient safety risks and hazards.
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effectivehealthcare.ahrq.gov/sites/default/files/ch_6-user-guide-to-ocer_130129.pdf
October 30, 2012 - alternatives
Clinical Outcomes:
Medical events that occur as a
result of disease or treatment
Clinical Indicators … thrombosis (ST)], and two relating to both safety
and effectiveness [composite of death, MI, ST, … The safety-only definition of MACE
yielded a hazard ratio of 1.75 (p<0.05), indicating
that patients … This construct
comprises outcomes from the patient perspective
and are measured by asking the patient … using clozapine may appear to have a worse safety
profile with respect to this outcome.
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pso.ahrq.gov/sites/default/files/wysiwyg/guidance-pswp-provider-obligations.pdf
May 24, 2016 - Slide 1
Patient Safety and Quality Improvement Act of 2005—HHS
Guidance Regarding Patient Safety Work … . “
• “The Patient Safety Act promotes the goal of improving patient
safety and reducing medical errors … 2005) Senator Enzi
• "Nor does this bill alter any existing rights or remedies available to
injured patients … Patient Safety Act Does Not Relieve a Provider From
Its External Obligations (1)
The Patient Safety … Patient Safety Act Does Not Relieve a Provider From
Its External Obligations (2)
The Patient Safety
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Fein.pdf
January 01, 2004 - safety is fundamental to high-quality patient care. … safety is fundamental to high-quality patient care. … Advances in Patient Safety: Vol. 2
484
system is aware of its errors. … Advances in Patient Safety: Vol. 2
488
Table 1. … UCLA
Healthcare Center for Patient Safety (LH) and Ethics Center (NW).
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psnet.ahrq.gov/node/33711/psn-pdf
May 01, 2011 - a patient safety event within the past year that
caused personal problems such as anxiety, depression … , length of professional relationships,
cases that involved pediatric patients, and the clinician's … One person provides peer support while a different individual (either patient safety expert or
https … Scott, RN, MSNCoordinator, Patient Safety, University of Missouri Health Care Doctoral
Student, University … J Patient Saf. 2007;3:107-119. [Available at]
17. Surveys on Patient Safety Culture.
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digital.ahrq.gov/ahrq-funded-projects/impact-office-based-e-prescribing-prescribing-processes-and-outcomes/annual-summary/2011
January 01, 2011 - This study evaluated the use of alerts and drug history, and the impact of e-prescribing on workflow, patient … safety, and patient adherence. … The project linked patients' e-prescriptions with pharmacy claims and generated a comprehensive dataset … Specific Aims:
Measure physician use of two safety-related e-prescribing functions: safety alerts … research to assess whether the adoption of e-prescribing is associated with improved clinical outcomes for patients
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www.ahrq.gov/sites/default/files/wysiwyg/hai/clabsi-tools/vascular-access-device-policy.pdf
March 01, 2008 - insertion of the line, assists with supplies and equipment, and
is expected to stop the procedure for any safety … High Risk Patients 1. Patients with a history of previous difficulty in placing a line.
2. … Module #2 Central Venous Access Training: Insertion and Safety Considerations
(includes required test … Performs discharge planning for patients with home infusion needs for the non-oncology
patients
Adult … The Central Line Insertion Care Team Checklist (see Appendix C) shall be used to monitor for
safety.
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www.ahrq.gov/sites/default/files/2025-02/raab-report.pdf
January 01, 2025 - Final Progress Report: Improving Patient Safety by Examining Pathology Errors
Improving Patient Safety … and Patient Safety. … Clinical laboratory specimen rejection: Association with the site of
patient care and patients' characteristics … Patient safety in pathology. … Update of patient safety.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cancer-anemia-update_disposition-comments.pdf
April 25, 2013 - or specific patient populations since
there is evidence that certain groups of patients may not
necessarily … However, that group was part of
the patient population defined for the review. … more in this manuscript because it is relevant to clinical practice and
it is the reason for ongoing safety … measures in accordance
with the AHRQ Methods Guide, these data are clinically important to consider for
safety … Since the 2008 ODAC meeting,
there have been no new safety signals that would warrant the conclusion
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www.ahrq.gov/sites/default/files/2024-07/peters-report.pdf
January 01, 2024 - Purpose: To examine patient risk perceptions of medical errors in order to anticipate how
patients will … safety,” whereas the media talks about medical errors. … Yet, it is not clear that the public even understands what the term “patient safety” means. … Factor 2 ,labeled Preventability, is patient oriented; patients can observe and prevent the
error. … Promoting patient safety by preventing medical error.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/153-cusp-tip-sheet-engaging-staff.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
CUSP Tip Sheet:
Engaging Unit Personnel in MRSA Prevention
ICU … & Non-ICU
Purpose
Unit-based teams are the cornerstone for Comprehensive Unit-based Safety Program ( … safety and quality improvement initiatives.
· Invite personnel who are not on the CUSP team to attend … stories and the impact that MRSA and healthcare-associated infections had on them, their patients, and … patients’ families.
· Be transparent, give useful and timely feedback, and be open to suggestions and
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/143-cusp-tip-sheet-engaging-staff.docx
April 01, 2025 - Comprehensive Unit-based Safety Program (CUSP) Tip Sheet:
Engaging Staff in MRSA Prevention
Surgical … safety and quality improvement initiatives.
· Invite personnel who are not on the CUSP team to attend … stories and the impact that MRSA and healthcare-associated infections had on them, their patients, and … patients’ families.
· Be transparent, give useful and timely feedback, and be open to suggestions and … | 1
CUSP Tip Sheet:
Engaging Staff
AHRQ Safety Program for MRSA Prevention | Surgical Services
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psnet.ahrq.gov/node/72739/psn-pdf
February 10, 2021 - safety
https://psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism … safety, ACR places shared responsibility on ordering physicians for timely follow-up of diagnostic … Approach to Improving Safety
This case represents a classic Swiss cheese model in which several, small … radiologic findings
Failure of the primary team to review imaging studies
Failure to recognize multiple indicators … safety and minimize diagnostic error.
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digital.ahrq.gov/sites/default/files/docs/publication/r01hs015413-samore-final-report-2008.pdf
January 01, 2008 - The program was designed primarily for safety,
ease of use, and capacity to integrate decision-support … safety features of the
CCOE, and their overall experience as INFORM project participants. … The topic of patient safety addressed two separate features of the CCOE tool: 1) the drug-
drug interaction … The other patient safety feature evaluated in the focus groups was the drug information in the
CCOE … The target enrollment was 75-100 patients from the first sampling frame and 175 patients
from the second