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  1. www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/pa-specialinnovation.html
    August 01, 2018 - Grant, 12 of CHOP’s primary care offices began implementing a fully-automated electronic screening system … Providers reported that the fully-automated electronic system minimized the amount of time that they … The electronic system also supports billing during the screening encounter and the ability to review … Families reported that the electronic system was easy to use and it allowed them to feel more involved … with 12 practices before going system-wide.
  2. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-datasources.pdf
    October 01, 2019 - Description The Behavioral Risk Factor Surveillance System (BRFSS) is the Nation’s premier system of … Description The Uniform Data System (UDS) is an integrated reporting system used by all grantees of … Resource and Patient Management System (RPMS) and National Patient Information Reporting System (NPIRS … Description The Medicare Patient Safety Monitoring System (MPSMS) is a nationwide surveillance system … The system tracks and monitors interactions with the healthcare system rather than health conditions
  3. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
    January 01, 2004 - (NYPORTS) mandatory adverse event reporting system to include the reporting of medication errors. … fixes instead of punitive fixes or inappropriate/incomplete system fixes. … and not the system. … To err is human: building a safer health system. … Albany (NY): New York Patient Occurrence Reporting and Tracking System. c2000–2002.
  4. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14053-Gandhi-draft-1.pdf
    April 16, 2007 - Gandhi 4.16.07 1 Scope: BWH developed a homegrown barcode/eMAR system to allow full integration … with the existing CPOE system. … The Brigham and Women’s hospital pharmacy converted to the barcoding system in September 2003. … A barcode-assisted dispensing system was implemented in three configurations. … The Medication Administration System-- Nurses Assessment of Satisfaction (MAS-NAS) scale.
  5. www.ahrq.gov/patient-safety/resources/resdesign-tool/kit4.html
    August 01, 2016 - Does the system have the resources to undertake the redesign process? … Implementation of an open access system. Diabetes disease management system. … What system metrics should we use to measure success? … These tools are frequently utilized in the Toyota Production System. … Lean (or the Toyota Production System) .
  6. www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/harrison-summit2016-breakout.pdf
    September 28, 2016 - for thinking about organizational factors • Research Examples: Foundations for future work Work System … community pharmacies, and ambulatory surgery centers • Teamwork ► TeamSTEPPS®: evidence-based teamwork system … evidence-based medicine o Initiative will develop a “Compendium” that will enable users to access health system … Appendix: AHRQ Resources • Comparative Health System Performance Initiative http://www.ahrq.gov/professionals … www.ahrq.gov/carecoordination Organizational Factors Affecting Diagnostic Quality Overview Work System
  7. www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast-keytakeaways.pdf
    August 01, 2018 - hospital providers and staff to address the following topic areas: Electronic Health Record (EHR) System … Training EHR System Support & Communication EHR Patient Safety & Quality Issues EHR & Workflow/Work … Process Overall EHR System Rating 2 What did we learn from the pilot test? … In the past 3 months... 66% discovered incomplete information in their EHR system 61% discovered
  8. The CAHPS Database (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/about/CAHPS-Database-Brief_01_2014.pdf
    January 01, 2014 - The CAHPS Database includes an Online Reporting System displaying aggregated data to facilitate comparisons … The CAHPS Online Reporting System is a Web-based platform for viewing Health Plan and Clinician … The reporting system consists of two major components:  a public site available to anyone with … Database are provided access to a secure, password-protected area of the CAHPS Online Reporting System … CAHPS Health Plan Survey Component CAHPS Clinician & Group Survey Component CAHPS Online Reporting System
  9. www.ahrq.gov/news/newsroom/case-studies/cp30909.html
    October 01, 2014 - MSeHA is a nonprofit, community-wide information system providing an electronic exchange of information … A total of 321 clinicians have used the system in five emergency departments since its initial deployment … Sands appreciates several aspects of the exchange, including how quickly data is entered into the system … The system has both inpatient and outpatient records; thus, I can see how compliant the patients are. … The system permits providers to review medical information faster than by individually contacting a patient's
  10. www.ahrq.gov/research/findings/final-reports/prospectscare/prospects1.html
    July 01, 2018 - Lack of data standardization and limited health IT system interoperability. … Return to Contents   Key Challenge Area 1: Underutilization of Health IT System Capabilities and … Challenge 1d: Underrepresentation of nonphysician viewpoints in health IT system design One panelist … Recommendations to Address Key Challenge Area 1: Underutilization of Health IT System Capabilities and … This variation stems partially from system customization that takes place during implementation.
  11. www.ahrq.gov/patient-safety/capacity/candor/demo-program/plan-grants/appa.html
    May 01, 2016 - By implementing a patient reporting system throughout Sanford Health System—a large, not-for-profit, … the Sanford Health System. … Prepared by Jackson Health System under grant number 1R21 HS19506-01. … Although one-third of respondents indicated the new system improved on the previous system, two-thirds … cases processed through the old system.
  12. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-science-safety.pptx
    May 01, 2017 - AHRQ Safety Program for Perinatal Care Science of Safety Health Care Defects In the U.S. health care system … patient 4 AHRQ Safety Program for Perinatal Care Science of Safety 4 The Science of Safety Every system … Factors Affect Safety6 6 AHRQ Safety Program for Perinatal Care Science of Safety 6 System-Level … Factors Can Predict Performance Examples of Impact of System-Level Factors System Factor Effect Nurse-to-patient … To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.
  13. Table 7B.1 (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7b.pdf
    February 02, 2018 - GAPPS study analytic sample (n= 3,442) Chronic Condition Indicators n (%) AE rate P-Value 0 body system … 1,935 (56.2%) 0.07 Reference 1 body system 1,067 (31.0%) 0.12 <0.001 2 body systems 315 (9.2%) 0.25 … analytic sample (n= 3,442) Chronic Condition Indicators (CCI) RRa (95% CIb) P-Value 0 body system
  14. www.ahrq.gov/sites/default/files/publications/files/ambulatory-safety.pdf
    July 01, 2010 - Funding: $986,302 Designs, develops, implements, and evaluates an interoperable quality information system … Adverse Drug Events in Ambulatory Pediatrics Estimated Total Funding: $992,699 Uses a computerized system … Dates: 9/30/2007–12/31/2009 Electronic Support for Public Health - Vaccine Adverse Event Reporting System … Focus Areas: AQA starter set for primary care (26 measures) Type of Health IT: System integration, quality … Focus Area(s): Patient self-management; shared decisionmaking Type of Health IT: System architecture,
  15. www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
    December 01, 2017 - Slide 7: Individual Mistake or System Failing? … While no system is perfect, we build redundancies into the care delivery system to compensate for minor … Slide 17: System Factors Impact Safety Say: Each level of the health care delivery system matters … Because emergencies strain any system. … The focus is on the system, not on the individuals.
  16. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
    December 01, 2017 - Slide 6 Individual Mistake or System Failing? … While no system is perfect, we build redundancies into the care delivery system to compensate for minor … Slide 16 System Factors Impact Safety SAY: Each level of the health care delivery system matters. … Because emergencies strain any system. … The focus is on the system, not on the individuals.
  17. www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/pa-specialinnovation.pdf
    August 01, 2015 - Sites gradually transitioned to the new system between 2011 and 2013, so the two different methods … Providers reported that the fully- automated electronic system minimized the amount of time that they … The electronic system also supports billing during the screening encounter and the ability to review … Families reported that the electronic system was easy to use and it allowed them to feel more involved … with 12 practices before going system- wide.
  18. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
    April 21, 2008 - The prototype included an event reporting system (the Medical Events Reporting System - Total HealthSystem … MERS-TH is a unique reporting system, since it is also a comprehensive error management system. … • Computerized charting system. … Trending and investigation reports are produced through the Midas system. … System changes are made as issues are identified.”
  19. www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/duration/chipra-154-section-7-b-icd-9-codes.pdf
    July 13, 2018 - septal closure 746 Other congenital anomalies of heart 747 Other congenital anomalies of circulatory system … Anencephalus & similar anomalies 741 Spina bifida 742 Other congenital anomalies of the nervous system … 748 Congenital anomalies of respiratory system 749 Cleft palate & cleft lip 750 Other congenital … anomalies of upper alimentary tract 751 Other congenital anomalies of digestive system 756 Other … congenital anomalies of musculoskeletal system 758 Chromosomal anomalies 759 Other unspecified congenital
  20. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Fitzgerald_108.pdf
    January 01, 2007 - Abstract This article describes challenges in the design and development of a decision support system … Future testing and development of this system will include a randomized clinical trial and technology … Introduction The development, testing, and validation of a real-time decision support system for use … The decision support system described in this article is part of the Trauma Reception and Resuscitation … Building a flexible protocol information system with ready for use web technology.

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