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ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.html
December 01, 2017 - ”
— James Reason, Human Error, 1990 1
Slide 8: AHRQ Safety Program for Surgery—Sustainability … Slide 25: References
Reason J. Human Error: models and management. BMJ 2000;320:768-70.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
January 01, 2004 - James Reason used the expression to describe what
often happens in the course of practical decisionmaking … Likelihood of detection
*Adapted from an original schema by Williams,47 a summary of which can be found in Reason … Reason J. Human error. Cambridge, UK: Cambridge
University Press; 1990.
22. Hammond KR. … Descartes’ Error: Emotion, Reason and
the Human Brain. New York: G. P. Putnam’s Sons;
1994.
34. … Reason J. Managing the risks of organizational
accidents.
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-6.html
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Scanlon_62.pdf
March 25, 2008 - Reason J. Human error. New York: Cambridge
University Press; 1990.
2. … Reason J. Human error: Models and management. … Reason J. Beyond the organisational accident: The
need for "error wisdom" on the frontline. … Reason J. Understanding adverse events: Human
factors. Qual Health Care 1995; 4: 80-89.
14. … Reason J. Safety in the operating theatre - Part 2:
Human error and organisational failure.
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ce.effectivehealthcare.ahrq.gov/research/findings/nhqrdr/chartbooks/personcentered/measures.html
June 01, 2018 - who experienced a communication barrier during their last doctor visit and reported language was the reason … difficulty understanding their doctor during their last visit, the percentage who reported language was the reason
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/root-cause.html
January 01, 2013 - ___ Trying to get in/out of bed to go to toilet/commode
___ Trying to get in/out of bed for other reason … bathroom/commode
___ Trying to reach/pick up something
___ Trying to get in/out of bed for another reason
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/2022-hospital-linkage-techdoc-021224.pdf
January 01, 2022 - Comments
Accessibility Results
Section 508
Index Checkpoint Status Reason Comments
WCAG … 2.0
Index Checkpoint Status Reason Comments
PDF/UA 1.0
Index Checkpoint Status Reason Comments … HHS
Index Checkpoint Status Reason Comments
HHS (2018 regulations)
Serial Page No … Element Path Checkpoint Name Test Name Status Reason Comments
1 Additional Checks 1. … WCAG 2.1
Index Checkpoint Status Reason Comments
Checkpoint Description:
Checkpoint Name
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state3.html
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May 01, 2024 - Health literacy
C-HL4
Provider talked with patient about reason
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ce.effectivehealthcare.ahrq.gov/cahps/surveys-guidance/item-sets/search.html?page=0
May 02, 2024 - Health literacy
C-HL4
Provider talked with patient about reason
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/partnering-executive-slides.pptx
June 01, 2021 - PowerPoint Presentation
Partnering With a Senior Executive
AHRQ Safety Program for Improving Antibiotic Use
Long-Term Care
AHRQ Pub. No. 17(21)-0029
June 2021
AHRQ Safety Program for Improving Antibiotic Use – Long-Term Care
Senior Executive
1
Objectives
Identify the qualities a senior executive brings to a team a…
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ce.effectivehealthcare.ahrq.gov/talkingquality/explain/support/explain-use.html
February 01, 2016 - Although helping people make a decision is often viewed as the primary reason for sharing comparative
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ce.effectivehealthcare.ahrq.gov/hai/cusp/clabsi-final-companion/clabsicompapa.html
January 01, 2013 - Article Exclusion List with Reason for Exclusion
Appendix D.
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ce.effectivehealthcare.ahrq.gov/hai/cusp/clabsi-final-companion/clabsicompapb.html
January 01, 2013 - Article Exclusion List with Reason for Exclusion
Appendix D.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/womenhealth/2014nhqdr-womenhealth.pptx
January 01, 2020 - 2012, the percentage of people without a usual source of care who indicated a financial or insurance reason … females were more likely to be without a usual source of care and indicate a financial or insurance reason … Overall Rate: In 2012, 22% of females without a usual source of care indicated a financial or insurance reason … females (33%) without a usual source of care were more likely to indicate a financial or insurance reason … and those with a high school education (26.7%) were more likely to indicate a financial or insurance reason
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/reducing-unnecessary-urinary-catheter-use-ed.pptx
August 10, 2012 - Reducing Unnecessary Urinary Catheter Use in the Emergency Department
Reducing Unnecessary Urinary Catheter Use in the Emergency Department
Margarita E. Pena, MD, FACEP
Medical Director, Clinical Decision Unit
St. John Hospital and Medical Center
Detroit, MI
Learning Objectives
Explain how to establish gui…
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-88-measure-1-section-14-attachment-1.pdf
January 01, 2011 - measure,
there must be a clear rationale to permit an exception for a medical, patient, or system reason … consideration – Please do not cite or distribute
15
Denominator
Exceptions
Documentation of medical reason … . patient with multiple psychiatric conditions referred to other provider)
Documentation of system reason
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-89-adhd-behavior-section-14-attach-1.pdf
January 01, 2011 - measure,
there must be a clear rationale to permit an exception for a medical, patient, or system reason … aged 4 through 18 years with a diagnosis of ADHD
Denominator
Exceptions
Documentation of medical reason … . patient with multiple psychiatric conditions referred to other provider)
Documentation of system reason
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ce.effectivehealthcare.ahrq.gov/patient-safety/reports/issue-briefs/dxchecklists-table1.html
September 01, 2020 - Skip to main content
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