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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Donaldson_87.pdf
April 23, 2008 - Coaches worked with sites to complete self-assessment surveys and to plan subsequent steps in
sustaining … A short formative survey was sent to
CNOs midway through the project to be completed by CNOs with linker … variables 52 96
Medications patient was on
at time of fall 27 75
Equipment in use 46 82
Patient … Intervals of fall risk assessment defined as:
Q shift on all patients 40 64
Q shift on at-risk … patients 36 4
Other 24 32
Fall risk assessment tool
Internally developed with reliability and
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www.ahrq.gov/news/events/nac/2019-07-nac/nacmtg0719-minutes.html
November 01, 2019 - We must focus on the whole person patient. … to support the enhancement of provider information and data resources and will be expanding provider surveys … Brady noted that AHRQ has considered that area and has added supplemental items in its patient safety … culture survey. … Focusing on high-cost patients does not necessarily save money.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/e1_combo_monitorprogress.pdf
June 02, 2025 - monitor after implementation will include rates for the AHRQ Inpatient Quality
Indicators (IQIs), Patient … If these
sources do not provide the needed data, you can use chart abstractions, surveys, new
administrative … To produce accurate reports for measures
that are calculated as rates (e.g., percentage of patients … with postsurgical infections), it is
important to have complete counts for the relevant patient populations … (e.g., all patients
who had surgery during a time period).
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www.ahrq.gov/hai/cusp/toolkit/content-calls/framework-slides/slides.html
October 01, 2014 - Comprehensive Unit-based Safety Program (CUSP): An Intervention to Learn from Mistakes and Improve Safety … Culture
Chris Goeschel, ScD MPA MPS RN FAAN
Director, Strategic Development and Research Initiatives … An intervention to learn from mistakes and improve safety culture. … Ensuring all patients receive the best practices. … Safety survey to identify at-risk departments.
Mandatory science of safety training.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-refs.html
August 01, 2023 - Pediatric Clinician Comfort Discussing Diagnostic Errors for Improving Patient Safety: A Survey. … A qualitative study of expert and team cognition on complex patients in the pediatric intensive care … Patient Safety Culture, Health Information Technology Implementation, and Medical Office Problems That … Resilient health care: turning patient safety on its head. Int J Qual Health Care . … Learning From Patients' Experiences Related To Diagnostic Errors Is Essential For Progress In Patient
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/05-sops-teamstepps-webcast-mazur.pdf
April 30, 2022 - sessions
hours
Recommendations
Integration
Recommend work-
system factors for
improvement based on … . huddles, closed-loop communication,
periodic planning, and updates)
1g Learns together, focuses on … behaviors averaged slightly above 2, with an overall average of 2.1 (range 1.9-2.2)
40
TENTS vs Patient … them from happening again. 84 +14
In this unit, we are informed about changes that are
made based on … At the unit level: Identify positive and negative aspects of culture
of patient safety and relate them
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case3.html
November 01, 2014 - Discontinued blood typing and screening on the day of surgery, since very few patients required blood … Patient survey results showed an increase in satisfaction with the discharge process in the first quarter … experiences, some of which were confirmed through patient surveys and other data. … Mixed results in terms of scores for patient satisfaction with discharge as reflected in patient surveys … In one Lean project, hourly checks on all patients led to a reduction in patient calls to the nursing
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/overview-fac-notes.html
June 01, 2017 - The two main program goals were to reduce surgical infection and complication rates and to improve safety … culture through improved teamwork and communication. … That particular center saw a 10 percentage-point increase in their patient safety culture survey, which … the previous day and any concerns for upcoming patients today. … Awareness of patient safety grows with increased outpatient surgeries .
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www.ahrq.gov/patient-safety/resources/learning-lab/yale-center-long-desc.html
June 01, 2020 - outcomes of transfers. 1-3 To support this work, it developed the following products:
Multiple survey … Real-time surveys reveal important safety risks during interhospital care transitions for neurologic … Real-time surveys reveal important safety risks during interhospital care transitions for neurologic … Clinician perspectives on goals of care for patients discharged from hospitals to skilled nursing facilities … Perspectives of clinicians at skilled nursing facilities on 30-day hospital readmissions: a qualitative
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr-intro-methods.pdf
December 01, 2021 - and patient safety culture. … Some survey designs, questionnaires, data collection methods, definitions, and data
calculation methods … Data Base (NCDB)
United States Census Bureau
• American Community Survey (ACS)
Populations
Overall … Disabilities: Disability status is defined based on the methodology of the American
Community Survey … Limitations With the Medicare Patient Safety Monitoring System Data
For these measures, “hospital patients
-
www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/implementing-cms-measure-slides.pdf
May 13, 2025 - Hatlie, JD
Patients for Patient
Safety U.S. … 4
Questions to Run On
• What is the Patient Safety Structural Measure? … Hatlie, JD
Co-founder and Director For Policy & Advocacy, Patients For Patient Safety US
The Patient … accountability
Culture of Safety and
Learning Systems
Hospital conducts hospital-
wide culture of safety survey … on safety-related activities
Patients have comprehensive
access to medical records via
patient portals
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www.ahrq.gov/sops/databases/asc/databases/submission.html
September 01, 2024 - Database Report presents aggregated results for all participating ASCs as well as results by ASC and respondent … ASCs that operate exclusively to provide surgical/procedural services to patients that do not require … Respondent-level survey data following the appropriate data file specifications for each ASC site. … that provides overall findings and results by ambulatory surgery center characteristics and staff respondent … the end of the survey, right before the background questions. * Note: Core survey items are the survey
-
www.ahrq.gov/sites/default/files/2024-01/scott-cawiezell-report.pdf
January 01, 2024 - explore the nursing home environments,
including key informant interviews, focus groups, and staff surveys … for patients who could not swallow. … intensive care units
(ICUs): Construct development, reliability, and validity of ICU Nurse-Physician Questionnaire … Technology implementation and workarounds
in the Nursing Home: Impact on Patient Safety. … Technology implementation and workarounds
in the Nursing Home: Impact on Patient Safety.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/learn/faclearncusp.docx
January 01, 2009 - Does your hospital do everything it can to protect patients? … Safety proved that CUSP was successful in improving the safety culture. … Frontline staff can use the modules to educate one another, patients, and physicians. … patient care and should be addressed when attempting to diagnose system-level influences on patient … correlated with considerable improvements in the safety climate in 71 units, as measured by a unit culture survey
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Teigland.pdf
March 01, 2004 - Short surveys were conducted during 2003, with followup contacts between
September 2003 and March 2004 … Based on utilization and survey feedback, the 91 participating nursing homes
were stratified into four … Based on our analyses of utilization and survey feedback, and considering the
success of programs using … In addition, a resident safety culture survey will be administered to a
sample of high and low use/integration … facilities to investigate whether nursing
home safety culture explains differences in use of the risk
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-toolkit.pdf
December 01, 2017 - on Patient Safety Culture at
https://www.ahrq.gov/sops/quality-patient-safety/patientsafetyculture … (GIM) practice’s use of the
Patient Experience Survey in this guide helped them
explore their patients … While most patients
indicated on the survey that they did know why a test
was ordered, the care teams … Purpose
The Patient Experience Assessment on page 14 can help you to assess your
patients' understanding … HANDOUT
Purpose
The Patient Handout on the next two pages can help you to engage patients in the
-
www.ahrq.gov/news/events/nac/2019-04-nac/nacmtg0419-minutes.html
July 01, 2019 - New reports on updated statistics from the Medical Expenditure Panel Survey (MEPS) and the Healthcare … Patients with multiple chronic conditions account for 64 percent of clinician visits, 70 percent of in-patient … Brady noted that AHRQ has considered that area and has added supplemental items in its patient safety … culture survey. … Focusing on high-cost patients does not necessarily save money.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf
July 02, 2008 - However, these forms focused on the biologic systems within the individual patient,
rather than on care … Thus, the health care paradigm
remained focused on the patient-physician relationship and on a therapy … Patient safety is a property dependent on open learning. … It also depends on both hands-on patient safety practices and leadership
within every discipline in … Error, stress,
and teamwork in medicine and aviation: Cross-
sectional surveys.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/overview/overview.pptx
May 01, 2017 - Awareness of patient safety grows with increased outpatient surgeries. … participated in 8 program cohorts
Program Goals
Reduce surgical infection and complication rates
Improve safety … culture through improved teamwork and communication
How can ASCs maintain effectiveness of safety practices … safety culture survey, attributed to the use of management practices
Module 1: Overview | ‹#›
AHRQ … Teams were able to surface and track problems such as missing items in kits and problems with reaching patients
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d1_combo_improvementmethodsoverview.pptx
June 02, 2025 - These slides may be useful earlier on in the process than during implementation; feel free to use them … Use Assessment of Organizational Readiness for Change related to the Inpatient Quality Indicators, Patient … Safety Indicators, and/or Pediatric Quality Indicators (Section A tools or AHRQ Survey on Patient Safety … Culture)
Review current performance on each of the metrics (Section B tools)
Determine priorities for … and Select Best Practices (Tools D.3, D.4)
Conduct a Gap Analysis (Tool D.5)
Select Best Practices on