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4901. AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Enhancing Healthcare Facility Design (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hcfd-rev.pdf
      November 01, 2023 - of Environments Aligned for Patient Safety (IDEA4PS) project led to improvements in the safety and quality … funded under contract number GS-00F-260DA/ 75Q80120F80007 from the Agency for Healthcare Research and Quality … to involving patients, families, and frontline staff in the design process and how that affects the quality … depth video rewind approach that may be useful for reviewing events that led to falls for postfall quality … technicians (RTTs), workload (WL), situational awareness (SA), and performance during pretreatment quality

4902. Making Healthcare Safer Practices: 10. Harms Due to Opioids (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/opioids-1.pdf
      March 01, 2020 - The candidate safety practices were discussed with the Agency for Healthcare Research and Quality (AHRQ … .7,12 10.1.4.2 Resources To Assist With Implementation • Centers for Disease Control and Prevention: Quality … • Improve the quality of future studies with control groups to account for secular trends, given the … test (UDT) • Pain clinics • Primary care All studies were observational and rated as poor to fair quality … effectiveness ratio of BUP relative to DETOX was $1,376 in terms of one-year direct medical cost per quality-adjusted

4903. Using the AHRQ Medical Office Survey on Patient Safety Culture (SOPS) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/using-medical-office-transcript.pdf
      April 29, 2011 - We want to evaluate the impact of patient safety and quality improvement initiatives using this as one … You see patient safety and quality issues listed under number one, which are more specific to medical … We also created the average rating on quality. … For average rating on quality, we see an 11 percentage point difference. … We see a similar small relationship with average rating on quality, and when we get to overall rating

4904. On-Time Falls Prevention: Electronic Reports (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxsamplereports.pdf
      November 06, 2017 - nursing; CNA = certified nursing assistant; NP = nurse practitioner; MDS = Minimum Data Set; QI = quality … Quality Improvement Review Rehab department staff Rehab Department Internal Review DON or ADON, nurse … Department heads, including administrator and medical director (or physician/NP designee) Quality

4905. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
      www.ahrq.gov/downloads/pub/advances/vol2/Schiff.pdf
      January 01, 2005 - AHRQ, only 1 is focused on diagnosis error, and none of the 20 evidence-based AHRQ Patient Safety Indicators … A report of the Committee on Quality of Health Care in America, Institute of Medicine. … Utilizing malpractice claims data for quality improvement. Legal Medicine 1992;92:1–3. 16. … Section 1: evidence-based quality improvement, principles, and perspectives. … Computer reminders, the quality of care and the nonperfectability of man.

4906. Implementing an Ambulatory e-Prescribing System: Strategies Employed and Lessons Learned to Minimize Unintended Consequences (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Devine_83.pdf
      April 06, 2008 - Sullivan, PhD Abstract Electronic health records are thought to improve quality of care; computerized … Introduction A recent systematic review of the impact of health information technology (HIT) on the quality … of medical care revealed that HIT interventions—primarily electronic health records (EHRs)— improve quality … Quality and efficiency must be built in with every step. … Crossing the quality chasm. A new health system for the 21st century. Institute of Medicine.

4907. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
      January 01, 2003 - The Agency for Healthcare Research and Quality (AHRQ), through its Risk Assessment Challenge Grant … Brennan offers five recommendations for improving quality through regulation. … regulatory/provider aims • Encourage provider self-improvement • Support innovation to improve quality … The role of regulation in quality. Milbank Qtrly 1998;76;709–32 22. Comden SC, Rosenthal J. … 30 >> /JPEG2000ColorImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /

4908. Just Culture Webcast November 2016 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-transcript-508-compliant.pdf
      June 01, 2017 - TeamSTEPPS, peer support learning following adverse events, and participation in the North Carolina Quality … November 2016 http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html … November 2016 http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html … Initially I reported to the VP for Quality, and then for the longest reporting period I reported to … This was going to be a partnership between the North Carolina Quality Center and Outcome Engineering

4909. The Use of Surgical Simulators to Reduce Errors (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Fried.pdf
      January 01, 2003 - trainees may be able to achieve a considerable level of prepatient expertise and provide a higher quality … Likewise, simulation technology and methodology can be used to improve the quality of surgical training … Acknowledgments This study was supported by the Agency for Healthcare Research and Quality, through … Total training systems design to function a total quality management application. … 30 >> /JPEG2000ColorImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /

4910. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/resources/liability/neumiller.html
      August 01, 2017 - In addition to patient safety and quality of care implications associated with the potential ADEs identified … Acknowledgments This project was funded by the Agency of Healthcare Research and Quality (AHRQ grant … Medicare quality improvement: bad apples or bad systems? JAMA 2003; 289:354-6. 3. … Medication Errors: Quality Chasm Series (pp. 1-25), Washington DC: National Academies Press; 2007.

4911. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/liability/neumiller.html
      August 01, 2017 - In addition to patient safety and quality of care implications associated with the potential ADEs identified … Acknowledgments This project was funded by the Agency of Healthcare Research and Quality (AHRQ grant … Medicare quality improvement: bad apples or bad systems? JAMA 2003; 289:354-6. 3. … Medication Errors: Quality Chasm Series (pp. 1-25), Washington DC: National Academies Press; 2007.

4912. On-Time Pressure Ulcer Prevention: Facilitator Training—Additional Exercises (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/addexercises.pdf
      March 03, 2025 - Evaluate impact of new programs or existing quality improvement efforts c. … Drive new quality improvement initiatives d.

4913. Improving the Value of Patient Safety Reporting Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
      June 12, 2008 - incident reporting was enacted in 2005.4 Under the auspices of the Agency for Healthcare Research and Quality … Acknowledgments Grant support was provided by the Agency for Healthcare Research and Quality (grant … Patient Safety and Quality Improvement Act of 2005. … How can clinicians measure safety and quality in acute care? Lancet 2004; 363: 1061-1067. 18.

4914. From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Kravitz.pdf
      February 09, 2005 - WARFDOCS is a tool designed to improve the quality of clinical decisions related to warfarin dosing. … They affect the quality of care by changing the processing and flow of information—in short, by changing … In light of this, it may be that the “quality of implementation” or even the “goodness of fit” between … Computer- adjusted dosage of anticoagulant therapy improves the quality of anticoagulation. … 30 >> /JPEG2000ColorImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /

4915. Introduction to the SPPC‐II Teamwork Toolkit for Obstetric Hemorrhage (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_1-introduction-speaker-notes.pdf
      July 01, 2023 - also known as SPPC‐ II) presented by the Johns Hopkins University, Agency for Healthcare Research and Quality … outcomes, AIM partners with State teams and health systems to align national‐, State‐, and hospital‐level quality … the adaptive skills that allow you to best engage in teamwork that keeps your patients’ safety and quality …                                                           SCRIPT AIM is a national data‐driven maternal safety and quality … Acknowledgments • This project is funded and implemented by the Agency for Healthcare Research and Quality

4916. Using the CAHPS Database to Compare, Report, and Improve Organizational Performance (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20140115_DB/Final_Using_the_CAHPS_Database_Webcast_Transcript.pdf
      January 01, 2014 - Study Director, CAHPS Database, Westat, Rockville, MD Deborah Kilstein, BSN, MBA, Vice President for Quality … Shaller (opening), Slide 2 Funded primarily by the Agency for Healthcare Research and Quality or AHRQ … We’ll then turn to our guest speakers, starting with Deborah Kilstein, Vice President for Quality Management … It allows us to evaluate performance based on comparable quality information, to focus on specific areas … The Agency for Healthcare Research and Quality is a federal agency that does research and works on best

4917. Final Progress Report: Management of Direct Anticoagulants to Lower Adverse Events in Atrial Fibrillation (MODL-AF) (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/king-report.pdf
      January 01, 2024 - This project was funded under grant number R18HS026156 from the Agency for Healthcare Research and Quality

4918. Evaluating Your TeamSTEPPS Intervention To Improve the Safety of LEP Patients | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps/lep/evalguide/lepevalguide.html
      December 01, 2012 - Agency for Healthcare Research and Quality Annual Meeting, Rockville, MD, September 2009. … B Return to Contents Unit Staff Pretraining Behavior Survey As part of our quality improvement … Did other quality improvement initiatives interfere with or enhance your TeamSTEPPS intervention?

4919. Strategy 3: Nurse Bedside Shift Report Implementation Handbook (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.docx
      August 01, 2010 - Introduction The Guide to Patient and Family Engagement in Hospital Quality and Safety is a resource … Department of Health and Human Services’ Agency for Healthcare Research and Quality by a collaboration … of partners with experience in and commitment to patient and family engagement, hospital quality, and … Bedside shift report can improve: Patient safety and quality. … Bedside handover: quality improvement strategy to ‘transform care at the bedside.’

4920. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
      January 01, 2024 - Preventing Medication Errors: Quality Chasm Series. … Dispensing errors and counseling quality in 100 pharmacies. … Quality and safety in the intensive care unit. … Rockville, MD: Agency for Healthcare Research and Quality; February 2005:379-393. … Total Quality Management: the route to improving performance. 2nd ed.