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3841. Implementation of a Data-based Medical Event Reporting System in the U.S. Department of Defense (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Davis.pdf
      February 12, 2004 - Implementation of a Data-based Medical Event Reporting System in the U.S. Department of Defense 235 Implementation of a Data-based Medical Event Reporting System in the U.S. Department of Defense Mary Ann Davis, Geoffrey W. Rake Abstract Objective: As a result of the Institute of Medicine (IOM) report, To…

3842. Beyond the Dusty Shelf: Shifting Paradigms and Effecting Change (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/McNeill.pdf
      January 01, 2004 - Beyond the Dusty Shelf: Shifting Paradigms and Effecting Change 383 Beyond the Dusty Shelf: Shifting Paradigms and Effecting Change Dwight McNeill, Howard Holland, Kerm Henriksen Abstract This paper addresses how to make happen the improvements in the quality of health care that have been identified from si…

3843. The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Meadows.pdf
      December 01, 2003 - The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents 387 The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents Sandra Meadows, Karen Baker, Jeremy Butler Abstract The National Patient Safety Agency has developed the Incident Decision Tree to hel…

3844. Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Johnson_90.pdf
      June 10, 2008 - Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work Julie K. Johnson, MSPH, PhD; Stephen H. Miller, M…

3845. Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
      May 05, 2008 - Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients Kshitij P. Mistry MD, MSc; James Jaggers, MD; Andrew J. Lodge, MD; Michael Alton, MSN, RN; Jane M. Mericle, BSN, RN, MHS-CL; Karen S. Frush, MD…

3846. Using Lean Six Sigma® Tools to Compare INR Measurements from Different Laboratories Within a Community (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Hurley_55.pdf
      March 07, 2008 - Using Lean Six Sigma® Tools to Compare INR Measurements from Different Laboratories Within a Community Using Lean Six Sigma® Tools to Compare INR Measurements from Different Laboratories Within a Community Brion Hurley, CSSBB; James M. Levett, MD, FACS; Carla Huber, ARNP; Tim L. Taylor, SSBB Abstract Whene…

3847. Practice and Quality Improvement | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-improvement.html
      May 01, 2024 - Investments in Primary Care Research for 2021 and 2022 Practice and Quality Improvement Previous Page Next Page Table of Contents Investments in Primary Care Research for 2021 and 2022 Acknowledgments and Authors Message from the Acting Director of AHRQ's National Center for Excellence in Primar…

3848. Tobacco Use and Dependence, General References (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/references/tobaccogenrefs.pdf
      January 01, 2010 - Tobacco Use and Dependence, General References General References 1. Fiore MC, Bailey WC, Cohen SJ, et al. Smoking cessation. Clinical Practice Guideline No. 18. Rockville, MD, U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication …

3849. 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 - AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and ED Visits 1 On-Time Preventable Hospital and ED Visits: Implementation On-Time Preventable Hospital and ED Visits Self-Assessment Scripted Exercise Team consists of:  Facilitator [Tom]  Program Champion (Quality Assessment and…

3850. Detailed Findings | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/findings.html
      August 01, 2022 - Demonstration Grants Final Evaluation Report Detailed Findings Previous Page Next Page Table of Contents Demonstration Grants Final Evaluation Report Executive Summary Detailed Findings Evaluation Issues Contributions to Patient Safety and Medical Liability Lessons Learned From Implement…

3851. Final Progress Report: Clinical Decision Support Simulations for Medication Administration Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/moss-berner-report.pdf
      January 01, 2024 - Final Progress Report: Clinical Decision Support Simulations for Medication Administration Safety Clinical Decision Support Simulations for Medication Administration Safety Principal Investigator: Jacqueline Moss, PhD, RN Co-Investigator: Eta S. Berner, EdD University of Alabama at Birmingham Dates of Aw…

3852. Presentation: Program Overview
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_overview_impmodel.pptx
      December 01, 2017 - Presentation: Program Overview Program Overview AHRQ Safety Program for Surgery Onboarding AHRQ Pub No. 16(18)-0004-15-EF December 2017 Overview ‹#› AHRQ Safety Program for Surgery – Onboarding SAY: You have embarked on a unique journey. 1 Never doubt that a small group of thoughtful, committed citizens ca…

3853. Slide 1
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/cauti-sustainability.pptx
      December 01, 2015 - Slide 1 CAUTI Sustainability: Embedding CAUTI Policies, Using Data to Monitor Progress and Hardwiring CUSP Principles 1 Diane Byrum, RN, MSN, CCRN, CCNS, FCCM Manager, Quality Implementation Programs Society of Critical Care Medicine William S. Miles, MD, FACS, FCCM, FAPWCA Director of Surgical Critical Care and the …

3854. Appropriate Emergency Department Blood Testing for Children with Sickle Cell Disease (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-215-fullreport.pdf
      August 01, 2017 - Appropriate Emergency Department Blood Testing for Children with Sickle Cell Disease Appropriate Emergency Department Blood Testing for Children with Sickle Cell Disease Section 1. Basic Measure Information 1.A. Measure Name Appropriate Emergency Department Blood Testing for Children with Sickle Cell Disease …

3855. Appropriate Emergency Department Fever Management for Children With Sickle Cell Disease (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-216-fullreport.pdf
      February 01, 2018 - Appropriate Emergency Department Fever Management for Children With Sickle Cell Disease 1 Appropriate Emergency Department Fever Management for Children with Sickle Cell Disease Section 1. Basic Measure Information 1.A. Measure Name Appropriate Emergency Department Fever Management for Children with Sickle Cel…

3856. 2022 Medicaid and Children's Health Insurance (CHIP) Chartbook (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2022-hp-chartbook.pdf
      January 01, 2022 - 2022 Medicaid and Children's Health Insurance (CHIP) Chartbook THE CAHPS DATABASES CAHPS Health Plan Survey Database 2022 Medicaid and Children's Health Insurance Program (CHIP) Chartbook What Enrollees Say About Their Experiences With Their Health Plans and Medical Care CAHPS Health Plan Survey Database …

3857. Cognitive Load Theory and Its Impact on Diagnostic Accuracy: Issue Brief (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-cognitive-load-theory.pdf
      May 01, 2024 - Cognitive Load Theory and Its Impact on Diagnostic Accuracy: Issue Brief PATIENT SAFETY e Issue Brief 17 Cognitive Load Theory and Its Impact on Diagnostic Accuracy This page intentionally left blank. e Issue Brief 17 Cognitive Load Theory and Its Impact on Diagnostic Accuracy Prepared for: Agency for…

3858. 2018 National Healthcare Quality and Disparities Report Data Sources (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-datasources.pdf
      October 01, 2019 - The CAHPS sampling recommendation is to achieve a minimum of 300 completed responses per health plan

3859. 2019 National Healthcare Quality and Disparities Report Data Sources (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-datasources.pdf
      December 01, 2020 - The CAHPS sampling recommendation is to achieve a minimum of 300 completed responses per health plan

3860. Apcd-Inventory (xls file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/apcd/apcd-inventory.xlsx
      October 01, 2015 - Sheet1 Measure Characteristics Overall Measure Inventory Details Deep Dive Measure Inventory Details Condition of Focus Measure Condition Subcategory Measure Type (Cost, Quality, or Utilization) Quality Category (Process, Outcomes, Structure, Not Applicable) Measure Name or Paper Name (From Lit Review) …