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  1. www.ahrq.gov/patient-safety/resources/learning-lab/ehrll-long-desc.html
    April 01, 2022 - Engineering High Reliability Learning Lab (EHRLL) Principal Investigator:  Sara Singer, Ph.D., Harvard University, Cambridge, MA AHRQ Grant No.:  HS24453 Project Period:  09/30/15–09/29/21 Description:  The goal of this learning lab was to enhance capacity for innovation and develop highly reliable system…
  2. www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hsops1-database-report-part-I.pdf
    March 01, 2021 - (Item A8*) 55% 8.32% 32% 45% 49% 55% 60% 65% 95% When an event is reported, it feels like the person … (Item A8*) 56% 55% 1% 14% -21% 5% -5% When an event is reported, it feels like the person is being
  3. www.ahrq.gov/sites/default/files/2024-01/aparasu-report.pdf
    January 01, 2024 - Elderly persons aged 65 years or older are usually covered by Medicare. … through Part B.42,43 Part A coverage for Medicare beneficiaries is automatic for eligible elderly persons … In 2010, Medicare provided coverage for 39 million elderly persons aged 65 years or older.44,45 About … A fall is a major event in the life of an older person. … The anticholinergic risk scale and anticholinergic adverse effects in older persons.
  4. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/reducing-adverse-drug-1.pdf
    March 01, 2020 - Prevention of hospital-acquired adverse drug reactions in older people using screening tool of older persons … Long-term outcomes of medication intervention using the screening tool of older persons potentially … Japanese patients: effects of pharmacists' assessment and intervention based on Screening Tool of Older Persons … Japanese patients: effects of pharmacists' assessment and intervention based on Screening Tool of Older Persons
  5. www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/ehr-reports.pdf
    March 01, 2016 - Exclusion Errors The fact that with exclusion errors the patient is not in the report means that the person
  6. www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-care-coordination.pdf
    June 30, 2025 - Hospitals received in-person training on the intervention. … Minneapolis, Minnesota R13 HS16371 [Grant] Using Clinical Guidelines to Improve the Care of Older Persons … restricted activity were strongly associated with development of a new functional impairment in older persons
  7. www.ahrq.gov/sites/default/files/publications/files/execsumm-lean-redesign.pdf
    March 01, 2017 - Spreading Lean: Taking Efficiency Interventions in Health Services Delivery to Scale - Executive Summary Executive Summary Spreading Lean: Taking Efficiency Interventions in Health Services Delivery to Scale Prepared for: Agency for Healthcare Research and Quality 5600 Fishers Lane …
  8. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/advanced-practice-guide-brochure.pdf
    March 01, 2016 - Resources for Advanced Practices Resources for Advanced Practices The Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Table of Contents Introduction ......................................................................1 Shared Decisionmaking .................…
  9. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/170-cusp-science-safety-notes.docx
    October 01, 2024 - AHRQ Safety Program for MRSA Prevention The Science of Safety: Principles in Practice ICU & Non-ICU Slide Title and Commentary Slide Number and Slide The Science of Safety: Principles in Practice SAY: Welcome to this presentation on the topic of “The Science of Safety: Principles in Practice.” As you consider esta…
  10. www.ahrq.gov/sites/default/files/2024-12/reeves-report.pdf
    January 01, 2024 - Final Progress Report: Developing a Rational Clinical Approach to the Disposition of TIA Cases in the ED 1 1. TITLE PAGE April 10th, 2012 Final Report Grant No: 1R03HS017740-01 Project Period: 07/01/2009 – 06/30/2010 (with 1-year no cost extension) Title: Developing a Rational Clinical Approach to the Dispositio…
  11. www.ahrq.gov/ncepcr/care/coordination/atlas/chapter3.html
    June 01, 2014 - Care Coordination Measures Atlas Update Chapter 3. Care Coordination Measurement Framework Previous Page Next Page Table of Contents Care Coordination Measures Atlas Update Chapter 1: Background Chapter 2. What is Care Coordination? Chapter 3. Care Coordination Measurement Framework Chapter …
  12. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docx
    April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI The Science of Safety: Principles in Practice Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries Slide Title and Commentary Slide Number and Slide The Science of Safety: Principles in Practice SAY: Welcome to this prese…
  13. www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/nh/nursing-home-family-span-1652b.pdf
    September 01, 2011 - CAHPS Nursing Home Survey: Family Member Instrument - Spanish CAHPS® Nursing Home Survey Version: Family Member Survey Language: Spanish Response Scale: 4 points For assistance with this survey, please contact the CAHPS Help Line at 800-492-9261 or cahps1@westat.com. File name: nursing-home-family-span-16…
  14. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/King.pdf
    January 01, 2002 - Systemwide Deployment of Medical Team Training: Lessons Learned in the Department of Defense 425 Systemwide Deployment of Medical Team Training: Lessons Learned in the Department of Defense Heidi B. King, Beth Kohsin, Mary Salisbury Abstract Advancing to a culture of safety requires a systems change. Teamw…
  15. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Simmons_66.pdf
    April 03, 2008 - 26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System 26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System Debora Simmons, RN, MSN, CCRN, CCNS; JoAnn Mick, PhD, RN, MBA, AOCN, CNAA, BC; Krisanne Graves, RN, BSN, CPHQ; Sharon K. Martin, ME…
  16. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
    May 01, 2003 - Physician Event Reporting: Training the Next Generation of Physicians 353 Physician Event Reporting: Training the Next Generation of Physicians Quang-Tuyen Nguyen, Joanna Weinberg, Lee H. Hilborne Abstract Physician reporting of adverse events and unsafe situations remains extremely low, despite the increa…
  17. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Stock_72.pdf
    January 01, 2007 - The PeaceHealth Ambulatory Medication Safety Culture Survey The PeaceHealth Ambulatory Medication Safety Culture Survey Ronald Stock, MD; Eldon R. Mahoney, PhD Abstract Objective: The objective of this project was to construct a measure of medication safety culture in ambulatory settings. Methods: A 16-it…
  18. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-qdr-appendixb-measure-category-7.pdf
    January 01, 2023 - multidimensional and essential to preventing adverse events, ensuring efficiency, and making care person … requires well-defined multidisciplinary teamwork based on the principle that all who interact with a person
  19. www.ahrq.gov/sites/default/files/2024-07/robins-report.pdf
    January 01, 2024 - study physician were screened to generate a list of eligible individuals whom we could approach in person
  20. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/g2_pdi_specifictoolstosupportchange.pdf
    January 01, 2011 - the changes that the team is testing, all the Plan-Do-Study-Act (PDSA) cycles for each change, the person … understand the importance of collecting accurate data on race, ethnicity, and primary language of persons

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