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www.ahrq.gov/sites/default/files/wysiwyg/funding/fund-opps/HS-24-003-webinar-slides.pdf
August 12, 2024 - Healthcare Research and Quality (AHRQ)
• AHRQ’s Mission:
► To produce evidence to make health care safer … without 501(c)(3) IRS Status (Other than
Institutions of Higher Education)
Refer to RFA section III … 30
Scored Review Criteria: Significance
• Does the project address an important problem or a critical
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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 - Turley, RN, PhD
Abstract
A critical step towards reducing errors in health care is the collection … In
its report, To Err Is Human: Building a Safer Health System, the Institute of Medicine (IOM)
estimated … Since the goal of this
ontology was to index the published literature, we felt it was critical that … computerized physician order entry (CPOE) system, which had a menu of several
possible doses of vasopressin; (iii … Conclusions
and Future Work
A critical step in the direction of reducing errors and adverse events
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pharmhealthlit/pharmlit/kripalani.ppt
January 01, 2010 - References
Davis TC, Wolf MS, Bass, PF III, Middlebrooks M, Kennen E, Baker DW, Bennett CL, Durazo-Arvizu … Making Healthcare Safer: A Critical Analysis of Patient Safety Practices.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/lepguide/lepguide.pdf
September 01, 2012 - iii
Foreword
The landmark Institute of Medicine report To Err Is Human was an influential and transformative … and Limited English Proficiency
The Institute of Medicine (IOM) report To Err is Human: Building a Safer … Patient Safety and LEP Populations
The Institute of Medicine (IOM) report To Err is Human: Building a Safer … improving care outcomes, team communication, and team
attitudes.21-24
TeamSTEPPS provides higher quality, safer … To err is human: building a safer health system.
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www.ahrq.gov/sites/default/files/publications/files/lepguide.pdf
September 01, 2012 - iii
Foreword
The landmark Institute of Medicine report To Err Is Human was an influential and transformative … and Limited English Proficiency
The Institute of Medicine (IOM) report To Err is Human: Building a Safer … Patient Safety and LEP Populations
The Institute of Medicine (IOM) report To Err is Human: Building a Safer … improving care outcomes, team communication, and team
attitudes.21-24
TeamSTEPPS provides higher quality, safer … To err is human: building a safer health system.
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www.ahrq.gov/research/findings/nhqrdr/chartbooks/intro.html
June 01, 2018 - Patient Safety: Making care safer by reducing harm caused in the delivery of care. … Ethnicity: Hispanic and non-Hispanic. ii
Income: Poor, low income, middle income, and high income. iii … Improving measurement and data for these groups is critical to understand the reasons they cannot access … iii.
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www.ahrq.gov/hai/pfp/hacrate2013-refs.html
October 01, 2015 - To err is human: building a safer healthcare system. … Toward improving the outcome of pregnancy III - enhancing perinatal health through quality, safety, and
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www.ahrq.gov/hai/pfp/interimhac2013-ref.html
December 01, 2014 - To err is human: building a safer healthcare system. … Toward improving the outcome of pregnancy III—enhancing perinatal health through quality, safety, and
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www.ahrq.gov/sites/default/files/publications/files/ltcmodule3.pdf
June 01, 2012 - ii
NOTES
iii
Falls Prevention and Management
Student Workbook
Contents
Learning and Performance … Also, we might feel frustrated that the
environment was not safer. … the care plan, including:
› More frequent blood pressure monitoring.
› More frequent toileting.
› Safer … knowledge of the resident’s history, and observations about
how this particular resident came to fall, are critical
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www.ahrq.gov/news/events/nac/2020-07-nac/nacmtg071420-minutes.html
November 01, 2020 - Kahn, III M.P.H., Federation of American Hospitals
Omar Lateef, D.O., Rush University Medical Center … Facilities as COVID-19 Skilled Care Centers Can Increase Hospital Capacity and Keep Nursing Home Patients Safer … The COVID-19 pandemic has revealed critical gaps in our knowledge of coordination logistics, the workforce
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www.ahrq.gov/sites/default/files/wysiwyg/news/events/nac/2020-07-nac/nacminutes-071420.pdf
January 01, 2020 - Kahn, III M.P.H., Federation of American Hospitals
Omar Lateef, D.O., Rush University Medical Center … Facilities as COVID-19 Skilled Care Centers Can Increase Hospital Capacity and Keep
Nursing Home Patients Safer … The COVID-19 pandemic has revealed critical gaps in our knowledge of coordination logistics,
the workforce
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www.ahrq.gov/sites/default/files/2024-01/mcalearney-report.pdf
January 01, 2024 - to have, and to test
innovative designs that had the potential to alter the status quo and shape a safer … Policy changes
included removing low-likelihood patient cohorts (Class III cardiac risk) from monitoring … Nursing Handovers in
Critical Care: A Retrospective Analysis of Information Content and Function. … “Simple Strategies for Safer Hospitals.” … Nursing Handovers in
Critical Care: A Retrospective Analysis of Information Content and Function.
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/mcalearney-report.pdf
September 29, 2020 - to have, and to test
innovative designs that had the potential to alter the status quo and shape a safer … Policy changes
included removing low-likelihood patient cohorts (Class III cardiac risk) from monitoring … Nursing Handovers in
Critical Care: A Retrospective Analysis of Information Content and Function. … “Simple Strategies for Safer Hospitals.” … Nursing Handovers in
Critical Care: A Retrospective Analysis of Information Content and Function.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-highlights-pfe-updated-aug24.pdf
February 28, 2025 - Parts I and III were rated positively but Part II (report card) needs refinement. … Arbaje
Johns Hopkins
University
Baltimore, Maryland
R01 HS26599
[Grant]
Making Health Care
Safer … safety to inform physicians, nurses, patients, and families about specific
ways to make healthcare safer … Key Findings/Impact: Understanding quantitative information about probabilities
is critical for health … Anna Beeber
University of
North Carolina
Chapel Hill, North
Carolina
R01 HS26473
[Grant]
A Safer
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-126-fullreport.pdf
May 01, 2018 - of serious drug interactions, delirium, serious behavioral
changes, cardiac arrhythmias, and death (Safer … be made explicit and transparent as
part of the public release of CHIPRA deliberations; thus, it is critical … group, or facility:** Can compare: (i) practice sites; (ii) medical or other
professional groups; or (iii … Antipsychotic polypharmacy in psychotic
disorders: A critical review of neurobiology, efficacy, tolerability … Psychiatr Serv 2011; 62:613-8.
23
Safer DJ, Zito JM, DosReis, S.
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www.ahrq.gov/sites/default/files/publications/files/interimhacrate2013_0.pdf
October 27, 2014 - patient harm since the Institute of Medicine’s
(IOM’s) 1999 publication of To Err Is Human: Building a Safer … RTI estimated that the difference in costs between patients
with hospital-acquired Stage III and Stage … IV pressure ulcers and matched patients without
hospital-acquired Stage III and IV pressure ulcers … Medicare Severity diagnosis-related group (MS-
DRG), sex, race, and age that did NOT have a Stage III … To err is human: building a safer healthcare system.
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www.ahrq.gov/sites/default/files/2024-11/golden-west-report.pdf
January 01, 2024 - One-Page Summary 5
III. Final Report 6
IV. Appendix A: List of Participants 12
V. … post-initiative data can document successes and challenges in reducing
patient risk, which can be critical … To Err is Human: Building a Safer Health System. Washington:
National Academy Press; 1999.
2.
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www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol2.pdf
July 01, 2023 - Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety
Practices. … AHRQ
Publication No. 20-0029-EF. https://www.ahrq.gov/research/findings/making-healthcare-safer/mhs3 … https://www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/index.html
https://www.ahrq.gov/research … /findings/making-healthcare-safer/mhs3/index.html
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4874935
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-148-fullreport.pdf
February 01, 2019 - Thus, clinicians may be underutilizing safer first-line psychosocial interventions in
children with … in foster care are more likely to be prescribed
antipsychotics than those not in foster care (Zito, Safer … be made explicit and transparent as
part of the public release of CHIPRA deliberations; thus, it is critical … group, or facility:** Can compare: (i) practice sites; (ii) medical or other
professional groups; or (iii … Zito JM, Safer DJ, Sai D, et al. Psychotropic medication patterns among youth in foster care.
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/qdr2015-ptschartbook.pdf
March 04, 2016 - Making care safer by reducing harm caused in the delivery of care.
2. … Data are from all
intensive care units, wards, and other non-critical care locations. … C
e
n
tr
a
l-
Li
n
e
D
ay
s
≤750 g 751-1,000 g
1,001-1,500 g 1,501-2,500 g
>2,500 g
Level III … C
e
n
tr
a
l-
Li
n
e
D
ay
s
≤750 g 751-1,000 g
1,001-1,500 g 1,501-2,500 g
>2,500 g
Level III … Making Health Care Safer II: An Updated Critical Analysis of the
Evidence for Patient Safety Practices