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digital.ahrq.gov/ahrq-funded-projects/using-electronic-records-detect-and-learn-ambulatory-diagnostic-errors/annual-summary/2010
January 01, 2010 - University of Texas Health Science Center - Houston
Funding Mechanism
RFA: HS07-002: Ambulatory Safety … The repositories contained all clinical data pertaining to patient care, including physician notes, laboratory … Journal of Medicine, “ Notification of abnormal lab test results in an electronic medical record: do any safety
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www.ahrq.gov/news/newsroom/press-releases/alcohol-use-disorders.html
November 01, 2023 - November 7, 2023
New research examines evidence-based practice to improve clinical decision making for patients … for AUD, including the use of drugs such as naltrexone, should be made collaboratively between the patient … “AHRQ’s updated systematic review examines how pharmacotherapy for patients with AUD can have a significant … Since the 2014 report, the literature on pharmacotherapy for patients with AUD has grown substantially … they focus on the strengths and limits of evidence from research studies about the effectiveness and safety
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www.ahrq.gov/ncepcr/research-transform-primary-care/transform/profile/donahue.html
August 01, 2018 - Location
North Carolina (49% rural)
Transformational Elements
Health Information Technology
Patient-Centered … Care
Quality & Safety
Overview of Transformation Efforts
The North Carolina Area Health … helped set goals for practice improvement, trained staff on QI methodology, and assisted in creating patient … to track implementation and use of disease registries, planned care templates, care protocols, and patient … Greater use of patient registries and protocols was associated with more patients achieving the cholesterol
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psnet.ahrq.gov/issue/effects-state-opioid-prescribing-laws-use-opioid-and-other-pain-treatments-among-commercially
October 13, 2018 - diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient … Impact of opioid administration in the intensive care unit and subsequent use in opioid-naïve patients … January 18, 2023
Inappropriate prescribing of opioids for patients undergoing surgery … Annual Perspective
Annual Perspective: Topics in Medication Safety … January 22, 2020
Potentially inappropriate medication use among elderly home care patients
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psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned
December 01, 2014 - Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients … National patient safety policy
2. Knowledge and learning in patient safety
3. … Patient safety awareness
4. Health services for patient safety
5. … and our Patients for Patient Safety program . … March 16, 2023
Failure to rescue as a patient safety indicator for neurosurgical patients
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb5txt.html
December 01, 2017 - Environment and Equipment Safety
Appendix A. References and Equipment Sources
Appendix B. … toilet seat
__ Use cushion in lounge chair
__ Lower lounge chair
__ Increase bathroom safety … __ Use adequate handrail support
__ Use easy to manage clothing
__ Promote wheelchair safety … surveillance
__ Position or pressure change alarm
__ Movement sensor
__ Locate patient … __ Corrective lenses
__ Keep eyewear within easy reach at all times
__ Encourage patient
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/039-mrsa-surveillance-slides.pptx
October 01, 2024 - Progressing to Clinical Disease5-8
Infection occurs when microorganisms on a patient cause adverse effects … population group will be cultured (e.g., all patients, patients from selected units, or high-risk patients … Contact precautions prevent the spread of diseases through direct contact with the patient or indirect … contact with environmental surfaces or patient-care items in the patient’s environment. … Wear gloves and gown to enter a patient room regardless of whether patient contact will occur.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/ptsd-5-protocol-update-2023.pdf
January 01, 2023 - reporting; (4) serve as a source for clinicians seeking information on
effectiveness of interventions for patients … meditation or "mind body" or mindfulness or music or "prolonged exposure" or
relaxation or "seeking safety … meditation or "mind body" or mindfulness or music or "prolonged exposure" or
relaxation or "seeking safety … Allowed PTSD psychotherapy, other psychotherapy, and psychotropic medication indicators
12. … Patients with suicidality excluded indicator
13.
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - encountered during the analytic phase typically resides with improper instrument operation, faulty reagents … April 18, 2018
Wake Up Safe in the USA & international patient safety. … August 7, 2024
Status of patient safety culture in community pharmacy settings: a systematic … August 23, 2023
Interventions to engage patients and families in patient safety: a systematic … implications of missed test results for hospitalised patients: a systematic review.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/implement/teamwork.pptx
January 01, 2007 - and safety
Units with little collaboration between disciplines
11
Daily Goals Checklist
This tool … What are patients’ greatest safety risks? … safety
Team members foster a climate where it is expected that assistance will be actively sought and … This is a SAFETY ISSUE! … Joint Commission Journal of Quality and Patient Safety. 2007 Jan;33(1):34-47.
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digital.ahrq.gov/ahrq-funded-projects/conversational-information-technology-it-better-safer-pediatric-primary-care/annual-summary/2010
January 01, 2010 - Organization
Boston Medical Center
Funding Mechanism
RFA: HS07-007: Ambulatory Safety … and Quality Program: Enabling Patient-Centered Care through Health Information Technology (PCC) … Health Partner: Conversational IT for Better, Safer Pediatric Primary Care, indicate that use of a patient-centered … Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered
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psnet.ahrq.gov/issue/automatable-algorithms-identify-nonmedical-opioid-use-using-electronic-data-systematic-review
July 27, 2016 - Safer opioid prescribing requires that providers and systems are able to identify patients who misuse … Problems with health information technology and their effects on care delivery and patient … rising frequency of IT blackouts indicates the increasing relevance of IT emergency concepts to ensure patient … safety.
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digital.ahrq.gov/ahrq-funded-projects/improving-communications-between-health-care-providers-statewide-infrastructure/annual-summary/2011
January 01, 2011 - utilizing the expanded cHIE infrastructure that includes an "Electronic Medical Record Lite," a master patient … While the impact of the use of cHIE by clinicians on patient safety and quality of care could not be … Strategic Goal: To develop and disseminate health IT evidence and evidence-based tools to support patient
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psnet.ahrq.gov/issue/role-medical-emergency-team-end-life-care-multicenter-prospective-observational-study
July 13, 2010 - In this study, conducted at seven hospitals in three countries, nearly one-third of patients seen by … February 1, 2023
Creating psychological safety in interprofessional simulation for health … Resources
Consumers' perspectives on their involvement in recognizing and responding to patient … June 2, 2010
The impact of Rapid Response System on delayed emergency team activation patient
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digital.ahrq.gov/ahrq-funded-projects/patient-centered-informatics-system-enhance-health-care-rural-communities
January 01, 2023 - Completed
Grant Number
R18 HS017308
Funding Mechanism(s)
Ambulatory Safety … This health information technology supports a new model of interaction between clinicians and patients … Enroll patients from the four participating rural clinics into a prospective cohort study to assess the … Distribution of physician letters to patients was an effective method of recruiting UHR users. … An analysis of UHR sessions indicated that medication refill, reconciliation functions, drug safety,
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hcup-us.ahrq.gov/news/exhibit_booth/HCUPOverviewDeck_121422.pdf
February 09, 2022 - elements are available:
► Value-added variables (supplemental variables for revisit
analyses, injury indicators … , indicators for observation and ED
services)
► Hospital characteristics (teaching status, ownership … Generate national and regional estimates
of inpatient utilization, access, quality,
patient safety … safety, etc. … safety, etc.
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www.ahrq.gov/hai/cusp/toolkit/content-calls/empowerment.html
April 01, 2013 - Well, how is CUSP different than other tools that we’ve used for patient safety? … This slide on Slide 6 is a snapshot of a badge card that Duke University’s patient safety program has … And so “huddles” has become a very generic term for a variety of strategies to improve patient safety … And in general, you have to have a culture that speaks up about patient safety. … But we also use the NDNQI which is National Database of Nursing Quality Indicators.
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www.ahrq.gov/sites/default/files/2025-02/delia-kutzin-report.pdf
January 01, 2025 - This would include
specific volume indicators, such as procedures per hospital, per physician, per EMT … This activity
could improve patient care and help hospital ED’s better manage their patient flow. … care over patient transport. … Expanding the implementation and usability of evidence-
based practice and rigorous patient safety protocols … This would include but not be limited to the development of evidence-based guidelines
and patient safety
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_ssi_investigation.pptx
December 01, 2017 - This is the Hospital Survey on Patient Safety Culture or HSOPS survey. … NOTE:
HSOPS stands for the Hospital Survey on Patient Safety Culture. … 3
Assess Your Performance
PROCESS DATA OUTCOME DATA
What we do to patients What happens to patients … SAY:
The process measures are what we do to patients to prevent harm. … The outcome data is what happens to those patients, such as an SSI.
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hcup-us.ahrq.gov/HCUP_Overview/HCUP_Overview/index508.jsp
September 01, 2025 - The SID
Some SID include synthetic patient linkage numbers that can be used to track patients within … After exclusions for missing or questionable patient linkage numbers and patients aged 0 years in some … AHRQ Quality Indicators (QIs) include:
Prevention Quality Indicators (PQIs) identify hospital admissions … Patient Safety Indicators (PSIs) focus on potentially avoidable complications and adverse events. … Quality is described in terms of six priorities: patient safety, person-centered care, care coordination