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  1. www.ahrq.gov/sites/default/files/2024-02/hoff-report.pdf
    January 01, 2024 - In addition, no attending surgeon ever found out about seven of the 15 floor mistakes and near misses
  2. www.ahrq.gov/sites/default/files/2024-07/gallagher3-report.pdf
    January 01, 2024 - Final Progress Report: Training Doctors To Disclose Unanticipated Outcomes to Patients: Randomized Trial R01HS016506 Final Progress Report 12-26-13; Gallagher TH, PI. 1 Title Page Title of Project: Training Doctors to Disclose Unanticipated Outcomes to Patients: Randomized Trial Principal Investigator and Team M…
  3. www.ahrq.gov/sites/default/files/2024-03/small-report.pdf
    January 01, 2024 - Final Progress report: Creating High Reliability Organizations Creating High Reliability Organizations Principal Investigator: Stephen D. Small, MD Key Team Members: Kay Metis, MS, MA Bobbie J. Sweitzer, MD Paul Barach, MD (2001-2002) Additional funded collaborators: Julie Mohr, PhD David Meltzer, MD, …
  4. www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/part2-cancer.html
    June 01, 2018 - Chartbook on Health Care for Blacks Part 2: Trends in Priorities of the Heckler Report—Care for Cancer Previous Page Next Page Table of Contents Chartbook on Health Care for Blacks Health Care for Blacks Acknowledgments Part 1: Overviews of the Report and the Black Population Part 2: Trends …
  5. www.ahrq.gov/sites/default/files/2024-11/kupka-report.pdf
    January 01, 2024 - the time out, other ASCs changed staff during the final time out, conducted the time out without the surgeon … preoperative assessment in the ASC setting and must communicate information among other nurses, the surgeon … Concerns are communicated by the nurse to the anesthesiologist, surgeon, or nursing and administrative
  6. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/b4_pdi_documentationcoding.pdf
    March 15, 2016 - Clinical scenario: During the removal of an abdominal mass, the surgeon documents, in the description … 03 Retained Surgical Item or Unretrieved Device Fragment X Foreign body intentionally left by surgeon
  7. Module-3-Slides (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-3-slides.pdf
    February 09, 2022 - Voice from the Field The Aspirus Wausau Hospital Cardiac Rehab Story of 2016 The Advice of a Surgeon
  8. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/45-iscr-pathway-audit-tool.xlsx
    June 01, 2023 - Introduction The compliance tracking sheet is located in the other tab of this Excel file AHRQ Pub. No. 23-0052 June 2023 &G Audit Tool Purpose of this tool: To support your hospital’s AHRQ Safety Program for Improving Surgical Care and Recovery (ISCR) implementation, your hospital should begin r…
  9. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/104-what-are-4-es.pptx
    April 01, 2025 - PowerPoint Presentation What Are the 4 Es? Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries AHRQ Pub. No. 25-0029 April 2025 AHRQ Safety Program for MRSA Prevention: Targeting SSI AHRQ Safety Program for MRSA Prevention | Surgical Services What Are the 4 Es? 1 Educational…
  10. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/standalone_psi_casestudy.pdf
    June 02, 2025 - To reach consensus on what steps to take to prevent DVT/PE, an HMC committee that included a trauma surgeon
  11. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Tool_11_PPT_508.pdf
    June 02, 2025 - 34 Strategy 1: Working With Patient and Family Advisors Training (Tool 11) Scenario 4 • A surgeon
  12. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Evanoff.pdf
    January 01, 2003 - Can We Talk? Priorities for Patient Care Differed Among Health Care Providers 5 Can We Talk? Priorities for Patient Care Differed Among Health Care Providers Bradley Evanoff, Patricia Potter, Laurie Wolf, Deborah Grayson, Clay Dunagan, Stuart Boxerman Abstract Objective: Poor communication and collabora…
  13. www.ahrq.gov/policymakers/chipra/overview/background/references.html
    April 01, 2025 - Mental health: A report of the Surgeon General. Washington, DC; 1999. 60.
  14. www.ahrq.gov/sites/default/files/2025-06/xu-report.pdf
    January 01, 2025 - Final Progress Report: Occult Uterine Cancer and Power Morcellation in Hysterectomy and Myomectomy AHRQ Grant Final Progress Report Project Title Occult Uterine Cancer and Power Morcellation in Hysterectomy and Myomectomy Principal Investigator and Team Members Principal Investigator: Xiao Xu, PhD Co-Investigator…
  15. www.ahrq.gov/sites/default/files/publications/files/confidreportguide_1.pdf
    March 01, 2016 - cardiac surgery program, a practice group of cardiothoracic surgeons, or uncommonly, an individual surgeon … ), Surgeon Group Q, for years 2012, 2013, and 2014. … The report also shows Surgeon Group Q compared with the percentage of patients with “any complication … a ti e n ts Any Complication Participant Like STS Isolated CABG Procedures Data Summary Surgeon
  16. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/navigating-hierarchy-transcript.doc
    December 10, 2013 - I have a colleague, John Webster, who’s a retired Naval orthopedic surgeon and when he and I met in the … And in the very back of the room, I noticed a surgeon who was in the back of the room and he’d been – … certain group of people so that we could back them up, and we went into one of the units where this surgeon … therapists, there were pharmacists and it was a pretty small classroom and everybody was packed in, and this surgeon
  17. www.ahrq.gov/hai/cauti-tools/archived-webinars/navigating-hierarchy-transcript.html
    December 01, 2017 - I have a colleague, John Webster, who's a retired Naval orthopedic surgeon and when he and I met in the … And in the very back of the room, I noticed a surgeon who was in the back of the room and he'd been – … certain group of people so that we could back them up, and we went into one of the units where this surgeon … therapists, there were pharmacists and it was a pretty small classroom and everybody was packed in, and this surgeon
  18. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/stpra/stpra.pdf
    March 01, 2012 - patients who received surgery in an ASC, experienced a complication, and returned to their private surgeon … A referral back to the surgeon should be performed for any concerns known to increase a patient’s risk … form of an SBAR, for example, might be used for a nurse to highlight a particular risk point to a surgeon
  19. www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb26.html
    December 01, 2017 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities Appendix B26: Reducing Falls: A Safety Checklist for the Home Previous Page Next Page Table of Contents The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities Chapter 1. Introductio…
  20. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-4.html
    August 01, 2023 - Pediatric Diagnostic Safety: State of the Science and Future Directions Diagnostic Safety Research Priorities and Opportunities Previous Page Next Page Table of Contents Pediatric Diagnostic Safety: State of the Science and Future Directions Introduction Challenges in Approaching Diagnostic Safe…

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