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1821. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
      June 30, 2004 - Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative 133 Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative Daniel M. Harris, John M. Westfall, Douglas H. Fernald, Christine W. Duclos, David R. West, Linda Niebauer, Linda Ma…

1822. Development of a Comprehensive Medical Error Ontology (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Mokkarala_103.pdf
      June 16, 2008 - Development of a Comprehensive Medical Error Ontology Development of a Comprehensive Medical Error Ontology Pallavi Mokkarala, MS; Julie Brixey, RN, PhD; Todd R. Johnson, PhD; Vimla L. Patel, PhD; Jiajie Zhang, PhD; James P. Turley, RN, PhD Abstract A critical step towards reducing errors in health care …

1823. 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 - Implementing an Ambulatory e-Prescribing System: Strategies Employed and Lessons Learned to Minimize Unintended Consequences Implementing an Ambulatory e-Prescribing System: Strategies Employed and Lessons Learned to Minimize Unintended Consequences Emily B. Devine, PharmD, MBA; Jennifer L. Wilson-Norton, RPh, MBA…

1824. Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
      April 07, 2008 - Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures Stanley Davis, MD; William Riley, PhD; Ayse P. Gurses, PhD; Kr…

1825. Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Woods_78.pdf
      July 23, 2008 - Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions Donna M. Woods, EdM, PhD; Jane L. Holl, MD, MPH; Denise Angst, PhD, RN; Susan C. Echiverri, MD; Daniel Johnson, MD; David F. Soglin, MD; Gop…

1826. Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Zierler_81.pdf
      September 01, 2008 - Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety Brenda K. Zierler, PhD; Ann Wittkowsky, PharmD; Gene Peterson, MD, PhD; Jung-Ah Lee, MN; Courtney Jacobson, BA; Robb Glenny, MD; Fred Wolf, PhD; Lynne Robin…

1827. Measuring IT Sophistication in Nursing Homes (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Alexander_10.pdf
      January 20, 2008 - Measuring IT Sophistication in Nursing Homes Measuring IT Sophistication in Nursing Homes Gregory L. Alexander, PhD, RN; Dick Madsen, PhD; Stephanie Herrick; Brady Russell Abstract Objective: Little activity has occurred in nursing home (information technology) IT adoption. The purpose of this study was to de…

1828. AHRQ Final report: Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/joseph1-report.pdf
      January 01, 2024 - AHRQ Final report: Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process TITLE PAGE Project Title: Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process Principal Investigator: Anjali Joseph, PhD, EDAC Tea…

1829. Final Progress Report: Enhancing the Safety of Warfarin in the Nursing Home (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/gurwitz-report.pdf
      January 01, 2024 - Final Progress Report: Enhancing the Safety of Warfarin in the Nursing Home Project Title: Enhancing the Safety of Warfarin in the Nursing Home Principal Investigator: Jerry H. Gurwitz, MD Principal Team Members: Jerry Gurwitz, MD; Terry S. Field, DSc; Jennifer Tjia, MD, MSCE; Kathleen M. Mazor, EdD; Leslie R. Ha…

1830. Final Grant Report: Using Military & Aviation Simulation Experience to Improve Rural Obstetric Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/guise2-report.pdf
      January 01, 2024 - Final Grant Report: Using Military & Aviation Simulation Experience to Improve Rural Obstetric Safety PI: Guise, J-M FINAL GRANT REPORT Title: Using Military & Aviation Simulation Experience to Improve Rural Obstetric Safety Grant Award #: 5U18HS015800-02 Grantee Institution: Oregon Health & Science University…

1831. Final Progress Report: Prescription Opioid Use Trajectories and Risk Factors Associated with Opioid-Related Hospitalizations in Older Adults (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/wei-report.pdf
      January 01, 2024 - Final Progress Report: Prescription Opioid Use Trajectories and Risk Factors Associated with Opioid-Related Hospitalizations in Older Adults AHRQ Grant Final Progress Report Prescription Opioid Use Trajectories and Risk Factors Associated with Opioid- Related Hospitalizations in Older Adults Principal Investigat…

1832. 0169 - Establishment of Gestational Age: Full Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/perinatal/chipra-169-fullreport.pdf
      February 01, 2017 - 0169 - Establishment of Gestational Age: Full Report Establishment of Gestational Age Section 1. Basic Measure Information 1.A. Measure Name Establishment of Gestational Age 1.B. Measure Number 0169 1.C. Measure Description Please provide a non-technical description of the measure that conveys what it measure…

1833. Webinar Transcript: Better Care, Healthier People and Communities, More Affordable Care: 5 Years of the National Quality Strategy | Agency for Healthcare Research and Quality
      www.ahrq.gov/workingforquality/events/webinar-better-care-healthier-communities.html
      November 01, 2016 - Webinar Transcript: Better Care, Healthier People and Communities, More Affordable Care: 5 Years of the National Quality Strategy May 17, 2016 Download accessible version of slides (PDF, 1.9 MB) Better Care, Healthier People and Communities, More Affordable Care: 5 Years of the National Quality Strategy…

1834. Developing and Sustaining State-Based Infrastructure To Support Primary Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/projects/state/how-to-guide/how-to-guide.pdf
      August 01, 2024 - • Recognize individual practice successes when a practice meets early and intermediate goals for … We recognize that future healthcare extension efforts will likely have a different focus and will identify

1835. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/match.pdf
      August 01, 2012 - TJC continues to recognize the importance of medication reconciliation, despite the need for several … It is important to recognize and understand these nuances, modify them as appropriate to minimize variations

1836. Network of Patient Safety Databases Chartbook, 2021 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2021.pdf
      January 01, 2021 - Network of Patient Safety Databases Chartbook, 2021 Network of Patient Safety Databases Chartbook, 2021 This document is in the public domain and may be used and reprinted without permission. Citation of the source is appreciated. Suggested citation: Network of Patient Safety Databases Chartbook, 2021. Rockvi…

1837. Imp-Handouts (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/imp-handouts.pdf
      June 02, 2025 - We recognize that anticoagulants are very high-risk medications.

1838. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Training | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereportguide.html
      September 01, 2017 - and physician orders provide information more quickly than MDS assessments and enable clinicians to recognize

1839. Final Progress Report: The ED Pharmacist as a Safety Measure in Emergency Medicine (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/fairbanks-report.pdf
      January 01, 2024 - Although there was a fairly high response rate, we must recognize that, without a 100% response rate,

1840. AHRQ Nursing Home Survey on Patient Safety Culture Version 2.0: User’s Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-users-guide-2.0.pdf
      March 01, 2025 - improve the safety and quality of care for patients and residents, nursing home leaders increasingly recognize