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401. 2021 National Healthcare Quality and Disparities Report: Executive Summary (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr-final-es.pdf
     January 01, 2021 - Key Findings and Trends All measures reported in the 2021 NHQDR were collected in 2019 or earlier,

402. Instructions for Analyzing Data from CAHPS Surveys (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/helpful-resources/analysis/2020-instructions-for-analyzing-data.pdf
     January 01, 2020 - This adjustment makes it more likely that reported differences are due to real differences in performance … We recommend choosing between these options based on the interpretation that will be given to the reported … For single-item responses, these adjusted means are reported. … In other words, reported p-values from the test are slightly larger than they should be, so significant … have subsequently merged their operations into a single business entity, and their results will be reported

403. National Center for Pediatric Practice-Based Research and Learning (C-PRL) (pdf file)
     pbrn.ahrq.gov/sites/default/files/docs/page/C-PRL.PDF
     May 01, 2015 - impact on pediatric asthma care of implementing a patient portal designed to educate, collect patient-reported

404. Chapter 3. Developing Change: Designing the Medication Reconciliation Process | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/patient-safety/settings/hospital/match/chapter-3.html
     July 01, 2022 - Linking medication reconciliation to other strategic goals (e.g., heart failure publicly reported process

405. How Learning Health Systems Learn: Lessons from the Field | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/learning-health-systems/how-lhs-learn.html
     May 01, 2019 - Pharmacy was reported as total costs of medication prescribed by the PCP, as well the rates at which

406. Section 6: Strategies for Improving Patient Experience with Ambulatory Care | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/index.html
     March 01, 2023 - Publicly reported quality-of-care measures influenced Wisconsin physician groups to improve performance

407. Monitoring for Perinatal Safety: Electronic Fetal Monitoring (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.pdf
     May 01, 2017 - SAY: Between 1996 and 2004, 34 percent of the cases of perinatal death or permanent disability reported

408. Preventing Falls in Hospitals
     pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module1/module1_slides_fallprev.pptx
     June 16, 2017 - They are the most frequently reported incident in adult inpatient units.

409. Improving Safety for Patients with Limited English Proficiency: TeamSTEPPS
     pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-oct2013.pptx
     January 01, 2013 - disparities Communication problems are the most frequent root cause of serious patient safety events reported

410. Surveys on Patient Safety Culture (SOPS) Nursing Home Survey: 2023 User Database Report Part I (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/SOPS-Nursing-Home-DB-Part-I-2023.pdf
     January 01, 2023 - response Highest Scoring Composite Measure: Feedback and Communication About Incidents 83% reported … Lowest Scoring Composite Measure: Staffing 39% reported they “strongly agree” or “agree” there … HIGHEST Scoring Composite Measure Feedback and Communication About Incidents 83% of respondents reported

411. : Practice-based Research Networks: Advancing Research and Quality of Care for Vulnerable Populations (pdf file)
     pbrn.ahrq.gov/sites/default/files/docs/page/VulnerablePopulations.pdf
     July 13, 2015 - North Texas Healthy Heart Study: The purpose of this study was to assess whether experiences of self-reported … Self-reported racial discrimination, response to unfair treatment, and coronary calcification in asymptomatic

412. How Two Provider Groups Are Using the CAHPS® Clinician & Group Survey for Quality Improvement (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/reports-and-case-studies/cgcahps-webcast-brief-2014.pdf
     January 01, 2014 - Results were reported back to physicians and practices quarterly. Ms.

413. Selected Best Practices and Suggestions for Improvement (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4d_combo_psi07-crbsi-bestpractices.pdf
     May 20, 2016 - • With a reported mortality rate of up to 35% and 14,000 to 28,000 associated deaths per year, hospitals

414. Improving Health Information Technology (IT) Patient Safety: A Resource List for Users of the AHRQ Health Information Technology Supplemental Item Set (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/patient-safety-technology-resources.pdf
     May 01, 2023 - The list does not enumerate the most frequently reported problems or the ones associated with the most

415. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
     August 01, 2022 - cross-checked their diagnosis with another physician by presenting a case and receiving feedback.42 The study reported … Diagnostic error in medicine: analysis of 583 physician-reported errors.

416. National Action Alliance to Advance Patient Safety Webinar Series (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/action-alliance/CMS-Aug-23-board-session.pdf
     August 22, 2023 - Board reviews patient-reported complaints and trends in patient experience and loyalty that indicate

417. Pain Management Injection Therapies for Low-back Pain: Topic Refinement (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/lbpinject-topicref.pdf
     March 03, 2014 - at some time in their lives, and a national survey of US adults in 2002 found that over one-quarter reported

418. An Overview of the CANDOR Process
     pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module8/module8-organizational-learning-sustainability.pptx
     August 20, 2015 - University of Missouri: Following development of a Care for the Caregiver program, the organization reported

419. Scisafetynotes (doc file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
     September 04, 2012 - This shift of authority led to a significant drop in the number of reported birth complications.

420. Staff Training Instructor Guide | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/teamstepps/lep/traintrainers/lepigstafftrain.html
     October 01, 2020 - All 18 reported situations where an interpreter was needed but was not present.