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2881. Webinar Transcript - The National Quality Strategy and the Public Sector: Federal Agency Alignment to the Six Priorities | Agency for Healthcare Research and Quality
      www.ahrq.gov/workingforquality/events/webinar-federal-agency-alignment-to-the-six-priorities.html
      November 01, 2016 - Webinar Transcript - The National Quality Strategy and the Public Sector: Federal Agency Alignment to the Six Priorities July 21, 2016 Download accessible version of slides (PDF, 1 MB) The National Quality Strategy and The Public Sector [Slide 1] Operator: Ladies and gentlemen, thank you for stand…

2882. 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…

2883. Final Progress Report: Promoting Safe Care Transitions: Simulation-Based Mastery Learning to Improve Communication in Times of Diagnostic Uncertainty (pdf file)
      www.ahrq.gov/sites/default/files/2025-04/rising-report.pdf
      January 01, 2025 - Final Progress Report: Promoting Safe Care Transitions: Simulation-Based Mastery Learning to Improve Communication in Times of Diagnostic Uncertainty Title Page TITLE: Promoting safe care transitions: Simulation-based mastery learning to improve communication in times of diagnostic uncertainty PRINCIPAL INVESTIG…

2884. 3. Assessment Plan and Methodology | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreen3.html
      April 01, 2018 - Health Care Systems for Tracking Colorectal Cancer Screening Tests 3. Assessment Plan and Methodology Previous Page Next Page Table of Contents Health Care Systems for Tracking Colorectal Cancer Screening Tests Executive Summary 1. Introduction 2. Description of the Intervention 2. Descripti…

2885. Planning and Implementing the Patient Advocacy Reporting System in the Sanford Health System | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/liability/pichert.html
      August 01, 2017 - Advances in Patient Safety and Medical Liability Planning and Implementing the Patient Advocacy Reporting System in the Sanford Health System Previous Page Next Page Table of Contents Advances in Patient Safety and Medical Liability Preface Acknowledgments Prologue Silence A Commentary Ref…

2886. Surveillance of Surgery-related Adverse Events in Missouri Using ICD-9-CM Codes (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Tuinen.pdf
      March 01, 2004 - Surveillance of Surgery-related Adverse Events in Missouri Using ICD-9-CM Codes 245 Surveillance of Surgery-related Adverse Events in Missouri Using ICD-9-CM Codes Mark Van Tuinen, Susan Elder, Carolyn Link, Susan Li, John H. Song, Tracey Pritchett Abstract Objectives: This study estimated the validity of 2…

2887. A Study of Adverse Occurrences and Major Functional Impairment Following Surgery (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Rojas.pdf
      March 15, 2004 - A Study of Adverse Occurrences and Major Functional Impairment Following Surgery 275 A Study of Adverse Occurrences and Major Functional Impairment Following Surgery Mary Rojas, Alan Silver, Christine Llewellyn, Lenora Rances Abstract Objective: The authors sought to ascertain whether adverse occurrences (AOs…

2888. Making Health Care Safer II, Executive Summary (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetysum.pdf
      March 01, 2013 - Making Health Care Safer II, Executive Summary Evidence-Based Practice Evidence-based Practice Program The Agency for Healthcare Research and Quality (AHRQ), through its Evidence- based Practice Centers (EPCs), sponsors the development of evidence reports and technology assessments to assist public- and priv…

2889. Observing Nurse Interaction with Infusion Pump Technologies (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Carayon.pdf
      January 01, 2004 - Observing Nurse Interaction with Infusion Pump Technologies 349 Observing Nurse Interaction with Infusion Pump Technologies Pascale Carayon, Tosha B. Wetterneck, Ann Schoofs Hundt, Mustafa Ozkaynak, Prashant Ram, Joshua DeSilvey, Brian Hicks, Tanita L. Robert, Myra Enloe, Rupa Sheth, Sade Sobande Abstract…

2890. From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Kravitz.pdf
      February 09, 2005 - From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator 395 From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator Richard L. Kravitz, Jonathan D. Neufeld, Michael A. Hogarth, Debora A. Paterniti, William Dager, …

2891. Standardizing Medication Error Event Reporting 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/vol4/Nosek.pdf
      March 01, 2004 - Standardizing Medication Error Event Reporting in the U.S. Department of Defense 361 Standardizing Medication Error Event Reporting in the U.S. Department of Defense Ronald A. Nosek, Jr., Judy McMeekin, Geoffrey W. Rake Abstract Soon after the 1999 Institute of Medicine report, To Err Is Human, was released, …

2892. 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 …

2893. Pillars of a Smart, Safe Operating Room (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Seagull_98.pdf
      April 07, 2008 - Pillars of a Smart, Safe Operating Room Pillars of a Smart, Safe Operating Room F. Jacob Seagull, MD; Gerald R. Moses, PhD; Adrian E. Park, MD Abstract Major gains in patient safety can be achieved through development of innovative approaches to the care of surgical patients. Investigators and clinicians have…

2894. National Healthcare Quality And Disparities Report Patient Safety Chartbook (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
      October 01, 2018 - Suggested citation: National Healthcare Quality and Disparities Report chartbook on patient safety.

2895. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report.pdf
      January 01, 2022 - Suggested citation: Rodrick D, Timashenka A, Umscheid C.

2896. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022: Preliminary Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-nov-rev.pdf
      January 01, 2022 - Suggested citation: Rodrick D, Timashenka A, Umscheid C.

2897. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-oct-rev.pdf
      January 01, 2022 - Suggested citation: Rodrick D, Timashenka A, Umscheid C.

2898. Eliminating CLABSI, A National Patient Safety Imperative: Final Report Companion Guide (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/clabsicompanion.pdf
      October 18, 2012 - units classified as ―needing improvement‖ (defined as a score of less than 50 percent, a threshold suggested

2899. Children With Disabilities Algorithm (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-144-fullreport.pdf
      January 01, 2020 - Children With Disabilities Algorithm Children with Disabilities Algorithm Section 1. Basic Measure Information 1.A. Measure Name Children with Disabilities Algorithm (CWDA) 1.B. Measure Number 0144 1.C. Measure Description Please provide a non-technical description of the measure that conveys what it measur…

2900. Making Healthcare Safer Practices: 16. Venous Thromboembolism (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/venous-thromboembolism-1.pdf
      March 01, 2020 - Making Healthcare Safer Practices: 16. Venous Thromboembolism Venous Thromboembolism 16-1 16. Venous Thromboembolism Eleanor Fitall, M.P.H., and Kendall K. Hall, M.D., M.S. Introduction Background Venous thromboembolism (VTE) is a disorder that includes deep vein thrombosis (DVT) and pulmonary embolism (PE). …