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  1. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load1.html
    May 01, 2024 - To Err Is Human , 2 a report published by the Institute of Medicine in 1999, was one of the first publications … This report suggested that diagnostic errors may contribute to 10 percent of all patient deaths.
  2. www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit1-2.html
    November 01, 2014 - Executives report a $29 million return on investment since 2000 when use of the external consultant's
  3. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/primer-patient-experience.pdf
    June 02, 2025 - What is Patient Experience and How Does CAHPS Measure It? WHAT IS PATIENT EXPERIENCE AND HOW DOES CAHPS MEASURE IT? Stephanie Fry Senior Study Director Westat 14 What is Patient Experience? Patient experience refers to what happened in a health care setting. It encompasses the range of interactions that pat…
  4. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/nyp-webinar-grob-prelim-phase-one.pdf
    June 02, 2025 - Implementing the New CAHPS® Protocol for Obtaining Patient Comments About Their Care Preliminary Findings from Phase One Rachel Grob, Ph.D. Director of National Initiatives and Clinical Professor, Center for Patient Partnerships Madison, WI www.ahrq.gov/cahps 0% 10% 20% 30% 40% 50% 60% 32 What’s Impor…
  5. www.ahrq.gov/news/newsroom/case-studies/201802.html
    August 01, 2018 - Connecticut Hospital Reduces Pressure Injuries Using AHRQ Toolkit Search All Impact Case Studies May 2018 Saint Francis Hospital and Medical Center, a 617-bed hospital in Hartford, CT, reduced hospital-acquired pressure injuries by more than 60 percent using an AHRQ toolkit. Preventing Pressure Ulcers in H…
  6. www.ahrq.gov/diagnostic-safety/research/index.html
    November 01, 2024 - Pediatricians self-report an appreciable number of diagnostic errors .
  7. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-indications.pptx
    April 01, 2022 - Centers for Disease Control and Prevention. 2019 National and State Healthcare-Associated Infections ProgressReport. https://www.cdc.gov/hai/data/portal/progress-report.html#2018.
  8. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-about-cusp.pptx
    May 01, 2017 - A Progress Report on the National On the CUSP: Stop BSI Project. AHRQ Publication No. 11-0037-EF.
  9. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/b4_pdi_documentationcoding.pdf
    March 15, 2016 - Policymakers are placing greater emphasis on quality performance and expect hospitals to report on clinical … It is recommended that there be an ongoing process in place to audit coding, track and report errors … Query the physician: • If the physician’s postoperative/procedure note and operative/procedure report … • If the postoperative/procedure note documentation conflicts with the operative/procedure report
  10. HIT Resource List (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/healthitresourcelist.pdf
    January 01, 2019 - Toolkit for the Safe Use of Copy and Paste Report https://www.ecri.org/Resources/HIT/CP_Toolkit/Toolkit_CopyPaste_final.pdf … Technology Toolkit for Critical Access and Small Hospitals Toolkit for the Safe Use of Copy and Paste Report
  11. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
    March 12, 2008 - MEDMARX data report, during 2003, 361 facilities submitted 8,862 records (4.1 percent) citing the dispensing … Making health care safer: A critical analysis of patient safety practices Evidence report/technology … MEDMARX 5th anniversary data report: A chartbook of 2003 findings and trends 1999-2003.
  12. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/035-importance-mrsa-prevention-notes.docx
    October 01, 2024 - To ensure that environmental cleaning is optimized, it is also important to monitor, measure, and report
  13. www.ahrq.gov/sites/default/files/publications2/files/dx-issue-brief-20-brazil-health-system.pdf
    August 01, 2024 - The health system uses an anonymous incident reporting system, enabling employees to report potential … While the comparison is not direct, we show the data from an AHRQ report on the results obtained from … Furthermore, a QR code was created in the report itself to facilitate diagnostic interactions with the … When the code is scanned, the team can report queries, make suggestions, and give feedback on the results … of the report.
  14. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.pdf
    June 02, 2025 - AHRQ Quality Indicators Prioritization Worksheet Example AHRQ Quality Indicators Toolkit Tool C.2 Volume of Cases at Risk Cost of Single Event Total Cost Cost To Implement Penalties and Incentives Proxies for Cost Strategic Alignment External Mandates Public Perception Executive- Level Support …
  15. 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 - Since the landmark Institute of Medicine (IOM) report focused national attention on patient safety, … In 1999, the IOM’s Committee on Quality of Health Care in America published the report, To Err is Human … Individuals in an organization must feel empowered to report errors, while organization leaders must … problems as they occur: Give people an easy avenue to report and communicate issues … A user's manual for the IOM’s “Quality Chasm” report. Health Aff 2002; 21: 80-90. 19.
  16. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/teach-back_quickstart_full.pdf
    September 15, 2016 - Skilled teach-back users report that it adds about 1 minute to the office visit, but the gain in patient … Start Guide: Teach-Back | 6 Implementation Notes Acrobat Accessibility Report … Accessibility Report Filename: TB-QSG-E-L-0.pdf Report created by: PFE Guide, PFEGuide@medstar.net … manual check: 2 Passed manually: 0 Failed manually: 0 Skipped: 0 Passed: 30 Failed: 0 Detailed Report
  17. www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/webinar02/spcslides.html
    July 01, 2013 - "Yes"      Let me see if I have a copy of that report.         … If you have a copy of that report, update health maintenance tab or make a note of date on progress … you do not have a copy, ask when/where it was done and give patient a record release to send for report
  18. www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-203-section-6-b-workgroup.pdf
    September 18, 2014 - Rice welcomed everyone and reminded the group that the final report on these measures is due the end … Dermatology, Transplant Surgery, Trauma Service (Implementation) Will include this feedback on final report
  19. www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-199-section-6-b-pmcoe-picu-expert-workgroup.pdf
    September 18, 2014 - Rice welcomed everyone and reminded the group that the final report on these measures is due the end … Dermatology, Transplant Surgery, Trauma Service (Implementation) Will include this feedback on final report
  20. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/qi-action-slides.pptx
    April 01, 2022 - in Action ׀ 25 25 Resources6-9 ICU Action Plan Template CUSP Learn From Defects Tool CAUTI Event Report … Tool CLABSI Event Report Tool Institute for Healthcare Improvement’s Plan-Do-Study-Act (PDSA) Worksheet … CAUTI Event Report Template. http://www.ahrq.gov/professionals/quality-patient-safety/hais/cauti-tools … Central Venous Catheter-Associated Laboratory-Confirmed Blood Stream Infection Event Report Template

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