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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-88-measure-1-section-2-attachment-1.pdf
February 01, 2012 - measure,
there must be a clear rationale to permit an exception for a medical, patient, or system reason … aged 4 through 5 years with a diagnosis of ADHD
Denominator
Exceptions
Documentation of medical reason … or patient determined to be at risk for harming themselves or others)
Documentation of system reason
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-89-adhd-behavior-section-2-attach-1.pdf
February 01, 2012 - measure,
there must be a clear rationale to permit an exception for a medical, patient, or system reason … aged 4 through 5 years with a diagnosis of ADHD
Denominator
Exceptions
Documentation of medical reason … ), or patient determined to be at risk for harming themselves or others)
Documentation of system reason
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load4.html
May 01, 2024 - Cognitive Load Theory and Its Impact on Diagnostic Accuracy
Measures of Cognitive Load
Previous Page Next Page
Table of Contents
Cognitive Load Theory and Its Impact on Diagnostic Accuracy
Introduction to Diagnostic Errors
Fundamental Concepts for Understanding Cognitive Load
Interplay Between…
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-last10-patients-audit.pdf
June 02, 2025 - Job Aid: “Last 10 Patients” Chart Audit
Primary Care Practice Facilitator
Training Series
1
Job Aid: “Last 10 Patients” Chart Audit
Overview
For a “last 10 patients” chart audit, look at the records of the last 10 patients the practice saw,
who should have received care or a service. Use a “last 10 …
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state3.html
January 01, 2024 - Current State of Diagnostic Safety: Implications for Research, Practice, and Policy
3. Results
Previous Page Next Page
Table of Contents
Current State of Diagnostic Safety: Implications for Research, Practice, and Policy
1. Introduction
2. Methods
3. Results
4. Discussion
References
Appe…
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www.ahrq.gov/hai/cauti-tools/archived-webinars/reducing-urinary-catheter-use-ed-slides.html
December 01, 2017 - Reducing Unnecessary Urinary Catheter Use in the Emergency Department
Slide Presentation
Slide 1
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
Image: Photo…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/170-cusp-science-safety-notes.docx
October 01, 2024 - SAY:
There is a reason that patient care is not handled by robots. … James Reason, an early influential researcher on human error and patient safety, wrote, “Rather than … Slide 16
Swiss Cheese Model
SAY:
James Reason was the first to describe the “Swiss Cheese Model,”
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docx
April 01, 2025 - SAY:
There is a reason that patient care is not automated or handled by robots. … James Reason, an early influential researcher on human error and patient safety, wrote, “Rather than … Slide 16
Swiss Cheese Model
SAY:
James Reason was the first to describe the “Swiss Cheese Model,”
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-1.html
June 01, 2020 - Operational Measurement of Diagnostic Safety: State of the Science
Introduction
Previous Page Next Page
Table of Contents
Operational Measurement of Diagnostic Safety: State of the Science
Introduction
Special Considerations for Measurement of Diagnostic Safety
Getting Ready for Measurement: O…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/healthsystem-key-drive-diagram.pdf
June 02, 2025 - Transcranial Doppler Screening for Children with Sickle Cell Anemia: Health System - Key Driver Diagram
Transcranial Doppler Screening for Children with Sickle Cell Anemia
Health System - Key Driver Diagram
Key Drivers
Strategies Global
Aim
To reduce the
incidence of
stroke in …
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses3.html
August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department
Nurses' Role in Diagnosis, Through the Lens of Distributed Cognition
Previous Page Next Page
Table of Contents
Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department
…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0085textdescription.pdf
January 01, 2012 - Clinical Topic
Text Description for PCPI eSpecification
Copyright 2012 American Medical Association and the National Committee for Quality Assurance. All rights reserved.
Clinical Topic Maternity Care
Measure Title Episiotomy (Overuse)
Measure # MC-7
Measure
Description
Percentage of patients, regardl…
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www.ahrq.gov/data/infographics/index.html
July 01, 2025 - Hospital Costs for Seniors with Traditional Medicare 2020 Heart Failure: Most Common and Expensive Reason
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/sustainability/premortem-scorecard-slides.pptx
January 01, 2017 - Mechanically Ventilated Patients
17
Premortem Exercise
Step 3
Identify the level of concern for each reason
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www.ahrq.gov/sites/default/files/2025-06/dean-report.pdf
January 01, 2025 - For this reason, the pneumonia pilot trial
was designed to include all participants over a 12-month … screening tool is to estimate the likelihood of
pneumonia among patients with a respiratory structured reason … Patients with accident as
reason for visit checked on the intake form were excluded.
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www.ahrq.gov/sites/default/files/2025-02/poghosyan-report.pdf
January 01, 2025 - Reason JT. Human error. New York, NY: Cambridge University Press; 1990.
14. … Reason J. … Reason J. Human error: models and management. BMJ. 2000;320(7237):768-70.
19. Stewart-Amidei C.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-mupirocin.docx
March 01, 2022 - If this 5-day course is interrupted for any reason, then follow the missed doses protocol.
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www.ahrq.gov/research/publications/ahrq-info-quality-gdlns.html
September 01, 2019 - days to resolve, the Agency will inform the complainant that more time is required and indicate the reason … days to resolve, the Agency will inform the complainant that more time is required and indicate the reason
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions2.html
June 01, 2023 - Notable examples include DE-PASS:
Decisive reason for admission,
Evaluation time,
Patient summary
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/aseptic-catheter-insertion-practices-inthe_ED_transcript.docx
June 02, 2015 - Another reason may be that health care providers may observe their peers inserting catheters and notice … Lack of importance is another reason or can be another barrier to successful insertion of ...