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2241. Missouri Hospitals Improve Medication Reconciliation Process Using AHRQ Toolkit | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsroom/case-studies/ktcquips93.html
      October 01, 2014 - Missouri Hospitals Improve Medication Reconciliation Process Using AHRQ Toolkit Search All Impact Case Studies April 2012 After participating in AHRQ-sponsored learning sessions and provider support calls, Primaris, the Missouri Quality Improvement Organization (QIO), worked with hospitals in the State to i…

2242. Electronic Exchange of Poisoning Information | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/electronic-exchange-poisoning-information
      January 01, 2023 - Electronic Exchange of Poisoning Information Project Final Report ( PDF , 688.55 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No stateme…

2243. Mod4-System-Focused-Event-Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-system-focused-event-guide.pdf
      April 01, 2016 - Purpose: To help teams adopt a system-focused approached to event investigation and analysis. Who should use this tool? Event Reporting, Investigation, and Analysis Team. How to use this tool: Review the guide information when developing and implementing a systems approaching to event investigation and analysis. T…

2244. CRP Certification: Promoting Accountability and Learning After Adverse Events (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/gallagher5-report.pdf
      January 01, 2024 - CRP Certification: Promoting Accountability and Learning After Adverse Events FINAL PROGRESS REPORT 1. Title Page Title of Project: CRP Certification: Promoting Accountability and Learning After Adverse Events Principal Investigator and Team Members: Thomas H. Gallagher, MD, Principal Investigator Karen Brigham…

2245. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840173/psn-pdf
      November 16, 2022 - Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings. November 16, 2022 Barrett TW, Garland NM, Freeman CL, et al. Ann Emerg Med. 2022;80(3):235-242.  https://psnet.ahrq.gov/innovation/catching-those-who-fall-thr…

2246. Fault Tree Analysis | Digital Healthcare Research
      digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/fault-tree-analysis
      January 01, 2023 - Fault Tree Analysis Acronym FTA Description Fault tree analyses (FTAs) study specific system, process, or product failures using a tree diagram . The process can be used to study a failure that actually occurred, or it could study a potential failure. The technique starts with the failure an…

2247. Table 1. Overview of studies on the effectiveness of checklists | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/issue-briefs/dxchecklists-table1.html
      September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction Table 1. Overview of studies on the effectiveness of checklists Previous Page Next Page Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction Introduction Rationale for Use…

2248. Benchmarking | Digital Healthcare Research
      digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/benchmarking
      January 01, 2023 - Benchmarking Examples Workflow-Related Questions for Benchmarking ( PDF , 675KB) Description Benchmarking is a process of evaluating metrics or best practices from other organizations (either related or unrelated to your own) and then applying them to your organization. Uses To f…

2249. Executive Summary | Agency for Healthcare Research and Quality
      www.ahrq.gov/professionals/systems/system/delivery-system-initiative/casalino/paper/idkeydsr1.html
      February 01, 2014 - Identifying Key Areas for Delivery System Research Executive Summary Previous Page Next Page Table of Contents Identifying Key Areas for Delivery System Research Executive Summary Identifying Key Areas for Delivery System Research Conclusion References Appendix A: Priority Topics Appendi…

2250. Final Progress Report: Improving ED Quality and Safety by Enhancing Operations and Quality Management (pdf file)
      www.ahrq.gov/sites/default/files/2024-09/khare-report.pdf
      January 01, 2024 - Final Progress Report: Improving ED Quality and Safety by Enhancing Operations and Quality Management FINAL PROGRESS REPORT Improving ED Quality and Safety by Enhancing Operations and Quality Management Principal Investigator: Rahul K. Khare, MD, formerly Assistant Professor of Emergency Medicine, Feinberg School o…

2251. Module-5-Implementation-Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-5-implementation-guide.pdf
      June 02, 2025 - TAKEheart Automatic Referral Implementation Guide - Module 5 Module 5 Implementation Guide: Building and Implementing a Successful Automatic Cardiac Rehab Referral System Purpose and Overview This implementation guide is designed to help you think through the steps you will need to address in designing and i…

2252. Understanding Health-Systems’ Use of and Need for Evidence To Inform Decisionmaking (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/health-systems-research.pdf
      October 01, 2017 - Understanding Health-Systems’ Use of and Need for Evidence To Inform Decisionmaking White Paper Understanding Health-Systems’ Use of and Need for Evidence To Inform Decisionmaking Research White Paper Understanding Health-Systems’ Use of and Need for Evidence To Inform Decisionmaking Prepared for: Agency …

2253. Stakeholder-Engagement-Benefits White-Paper (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/stakeholder-engagement-benefits_white-paper.pdf
      March 01, 2014 - Research White Paper Defining the Benefits of Stakeholder Engagement in Systematic Reviews Research White Paper Defining the Benefits of Stakeholder Engagement in Systematic Reviews Prepared for: Agency for Healthcare Research and Quality U.S. Departm…

2254. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45708/psn-pdf
      October 31, 2017 - Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU. October 31, 2017 Bates KE, Shea JA, Bird GL, et al. Development and Preliminary Testing of the Coordination Process Error Re…

2255. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44179/psn-pdf
      November 20, 2015 - Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative exploration of patient and provider perspectives. November 20, 2015 Litchfield I, Bentham L, Hill A, et al. Routine failures in the process for blood testing and the communication…

2256. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838242/psn-pdf
      January 01, 2023 - Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology. October 5, 2022 Clayton DA, Eguchi MM, Kerr KF, et al. Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology. Med Decis Making. 2023;43(2):164-17…

2257. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45874/psn-pdf
      February 22, 2017 - Ethics in the pediatric emergency department: when mistakes happen: an approach to the process, evaluation, and response to medical errors. February 22, 2017 Dreisinger N, Zapolsky N. Ethics in the Pediatric Emergency Department: When Mistakes Happen: An Approach to the Process, Evaluation, and Response to Medical…

2258. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43626/psn-pdf
      November 05, 2014 - Effects of skilled nursing facility structure and process factors on medication errors during nursing home admission. November 5, 2014 Lane SJ, Troyer JL, Dienemann JA, et al. Effects of skilled nursing facility structure and process factors on medication errors during nursing home admission. Health Care Manag Rev…

2259. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47537/psn-pdf
      November 14, 2018 - Developing a learning health system: insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care. November 14, 2018 Jeffries M, Keers RN, Phipps D, et al. Developing a learning health system: Insights from a qualitative …

2260. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42281/psn-pdf
      May 22, 2013 - The effect of computerized provider order entry systems on clinical care and work processes in emergency departments: a systematic review of the quantitative literature. May 22, 2013 Georgiou A, Prgomet M, Paoloni R, et al. The effect of computerized provider order entry systems on clinical care and work processe…