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581. Final Progress Report: Cook County & Rush Developmental Center for Research in Patient Safety: Diagnosis Error Evaluation and Research (DEER) Project (pdf file)
     www.ahrq.gov/sites/default/files/2025-04/schiff-mcnutt-report.pdf
     January 01, 2025 - measures failure to diagnose. 4 Although, for each of these AHRQ 20 “sentinel complications” (e.g., decubitus … ulcer, iatrogenic pneumothorax, post-op septicemia, accidental puncture/laceration), timely diagnosis

582. 2022 National Healthcare Quality and Disparities Report Data Sources (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-datasources.pdf
     December 01, 2022 - Healthcare-associated Infection Patients with one or more falls during stay Fall Stays with one or more pressure … ulcer adverse events Pressure Ulcer Venous thromboembolism/pulmonary embolism (VTE/PE) not related

583. Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/confidreportguide_1.pdf
     March 01, 2016 - in hospitals, as well as related component measures, such as an A1c value less than 8 percent, and pressure … ulcer rate, for primary care clinicians and hospitals, respectively

584. 2023 National Healthcare Quality and Disparities Report Data Sources (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023qdr-data-sources.pdf
     December 01, 2023 - Healthcare-associated Infection (HAI) Patients with one or more falls during stay Fall Stays with one or more pressure … ulcer adverse events Pressure Ulcer Venous thromboembolism/pulmonary embolism (VTE/PE) not related

585. Final Progress Report: What About Mom? Using Administrative Data To Develop Measures for Monitoring Healthcare Quality in Pregnancy & Childbirth (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/gregory-report.pdf
     January 01, 2024 - they were deemed to be not relevant for this population (PSI #2: Death in low-mortality DRGs, PSI #3: Decubitus … ulcer, PSI #4: Failure to rescue, PSI #6: Iatrogenic pneumothorax, PSI #7: Selected infections due

586. Case 3. Grand Hospital Center | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case3.html
     November 01, 2014 - other metrics include: turnaround time, number of procedures, cost reports, or frequency of falls or pressure … ulcers.

587. Standardized infection ratios for central line-associated bloodstream infections and surgical site infections, 2009–2012
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt3.pptx
     September 19, 2015 - restrained daily can become weak, lose their ability to go to the bathroom by themselves, and develop pressure … ulcers or other medical conditions.

588. Environmental Scan of Patient Safety Education and Training Programs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/environmental-scan-programs/envptscan.pdf
     June 01, 2013 - Complications 26 429 -- Delirium 2 427 -- Nosocomial Infections 3 450 -- Patient Falls 11 428 -- Pressure … Ulcers 5 430 -- Venous Thrombosis and Thromboembolism 0 414 Medication Safety 126 416 -- Medication

589. Evaluation and Research on Antimicrobial Stewardship's Effect on Clostridium difficile (ERASE C. difficile) Project: toolkit (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/cdifftoolkit.pdf
     September 01, 2012 - Source: Developed by AHRQ Pressure Ulcer Prevention Toolkit project team.

590. Final Progress Report: Making Acute Care More Patient Centered, Patient Safety Learning Laboratory (PSLL) (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/bates3-report.pdf
     January 01, 2024 - Bowel Regimen, Venous Thromboembolism (VTE) Prophylaxis, Opioid Management, Antibiotic Management, Pressure … Ulcer Prevention and Management, Delirium Management, Fall Risk, Vascular Access, Urinary Catheter

591. QDR 2014: Chartbook for Hispanic Health Care, Part 3 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt3.pdf
     June 01, 2014 - restrained daily can become weak, lose their ability to go to the bathroom by themselves, and develop pressure … ulcers or other medical conditions

592. Final Progress Report: Using Team Simulation to Improve Error Disclosure to Patients and Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/gallagher2-report.pdf
     January 01, 2024 - Final Progress Report: Using Team Simulation to Improve Error Disclosure to Patients and Safety Culture AHRQ Grant Final Progress Report Title of Project: Using Team Simulation to Improve Error Disclosure to Patients and Safety Culture Principal Investigator: Thomas H. Gallagher, MD Co-Investigators: Sarah Shann…

593. Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/confidreportguide_0.pdf
     March 01, 2016 - in hospitals, as well as related component measures, such as an A1c value less than 8 percent, and pressure … ulcer rate, for primary care clinicians and hospitals, respectively

594. Improving Healthcare Safety by Enhancing Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-medication-safety.pdf
     April 30, 2025 - Improving Healthcare Safety by Enhancing Medication Safety AHRQ-Funded Patient Safety Project Highlights Improving Healthcare Safety by Enhancing Medication Safety Overview Medication safety refers to the practices and measures implemented to minimize the risk of medication errors and adverse drug events (ADEs) i…

595. Department of Health and Human Services National Institutes of Health - National Institute for Research on Safety and Quality (NIRSQ) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cpi/about/mission/budget/2021/FY_2021_CJ_NIRSQ.pdf
     January 01, 2021 - Rounds on the Web); • AHRQ QuestionBuilder App; • AHRQ’s Safety Program for Nursing Homes: On-Time Pressure … Ulcer Prevention; • Common Formats (standardized specifications for reporting patient safety events