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www.ahrq.gov/news/newsletters/e-newsletter/944.html
January 01, 2025 - Register Now: Feb. 10 Webinar Will Highlight Evidence on Advancing Rapid Response Systems and Opioid … Register Now: Feb. 10 Webinar Will Highlight Evidence on Advancing Rapid Response Systems and Opioid … reviews rapid response systems’ impacts on patient safety and clinical outcomes, and ways rapid response … systems can be implemented effectively. … Organizations that participate in AHRQ’s Implementing Diagnostic Excellence Across Systems (IDEAS) project
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www.ahrq.gov/sites/default/files/wysiwyg/pcor/pcortf-strategic-framework.pdf
June 01, 2023 - Those include patients, healthcare professionals, health systems, professional
associations, vendors … Transformation of healthcare organizations into learning health systems.
2. … The model also aims to make health systems
better places to work. … /products/health-systems-use-evidence/overview? … in their iterative, continuous
improvement journeys toward becoming learning health systems.
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www.ahrq.gov/evidencenow/tools/keydrivers/description.html
October 01, 2020 - Embed selected evidence and guidelines into clinical information systems
Research shows that relying … Functional clinical information systems can make it easier for teams to adhere to agreed-upon actions … Embedding processes into information systems decreases the chance that any steps will be skipped, has … , such as registries and laboratory systems, to fill the gaps. … Electronic systems may require the addition of new fields and paper-based systems will need a coherent
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www.ahrq.gov/news/events/nac/2020-07-nac/nacmtg071420-minutes.html
November 01, 2020 - and Provider Database and, at AHRQ itself, of a compendium of U.S. health systems (almost 700 systems … Consider a systems-engineering approach for responding to COVID-19. … AHRQ has been partnering with systems-engineering experts. … How are healthcare systems reestablished? Dr. … Secretary Azar is visiting States and delivery systems.
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www.ahrq.gov/patient-safety/reports/liability/pichert.html
August 01, 2017 - Systems
8. … Systems. … Systems-Related Lessons. … , so long as the necessary people, processes, and systems are in place. … Patients as observers and reporters in support of systems and patient safety.
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www.ahrq.gov/news/events/nac/2018-07-nac/nacmtg0718-minutes.html
July 01, 2021 - Today’s studies of learning health systems are in need of data. … Health systems are not presented with a scope in addressing social determinants. … What systems are respecting and communicating that well, especially in pediatrics?
Drs. … Health Systems. … We should support curricula that can be transferred to lower levels of systems.
Shari M.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Wideman.pdf
April 20, 2004 - In: VISTA (Veterans Health
Information Systems & Technology Architecture)
Health Systems Design & Development … VISTA (Veterans
Health Information Systems & Technology
Architecture) Health Systems Design & Development … In: VISTA (Veterans Health Information
Systems & Technology Architecture) Health Systems
Design & Development … In: VISTA (Veterans
Health Information Systems & Technology
Architecture) Health Systems Design & Development … In: VISTA (Veterans Health
Information Systems & Technology Architecture)
Health Systems Design & Development
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/engage/rfe-brochure.pdf
March 01, 2017 - Working With Patients and
Families as Advisors. 2013. http://www.
ahrq.gov/professionals/systems/hospital … tipsforgroupleaders.pdf
http://www.ipfcc.org/advance/tipsforgroupleaders.pdf
http://www.ahrq.gov/professionals/systems … /hospital/engagingfamilies/strategy1/index.html
http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies … /strategy1/index.html
http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy1/index.html
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Rundall.pdf
January 01, 2003 - semistructured interviews among a sample of practicing physicians from 3
integrated health delivery systems … Other subjects used pharmacy support systems. … Respondents also noted the value
of pharmacy support systems. … Third, all of the health systems were
relatively large integrated delivery systems, which arguably may … Characteristics of three integrated delivery systems (1999 data)*
Table 2.
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www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chap6tab28.html
December 01, 2017 - Fiscal year 2010
Findings from a set of 16 grants on improving delivery systems and on spreading evidence-based … practices through delivery systems; recommendations and methods for advancing delivery system research … Presentations, topical papers and briefs on advanced methods, critical areas, and challenges for Delivery Systems
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight01.pdf
September 30, 2015 - • Outdated or underdeveloped claims systems, health information exchanges,
and electronic health … In some
cases, States were overly optimistic
in their plans to link existing data
systems, such as … claims systems
and immunization registries, and to
use newly developed information
exchange systems … However, their
needs often went beyond what current
IT systems could provide. … Collecting data from State-level data
systems.
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight01.html
March 01, 2019 - Outdated or underdeveloped claims systems, health information exchanges, and electronic health records … systems and immunization registries, and to use newly developed information exchange systems to calculate … However, their needs often went beyond what current IT systems could provide. … Two States that actively engage practices in data collection are developing systems that include EHR … Collecting data from State-level data systems .
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www.ahrq.gov/sites/default/files/2025-04/nemeth-report.pdf
January 01, 2025 - Methods: The study’s cognitive systems engineering approach included six methods. … (2005:3) have identified as the most promising tools for healthcare systems engineering. … Cognitive Systems Engineering. In Helander, M. (Ed.). Handbook of
Human-Computer Interaction. … Sharpening the Sword: Human Factors Research for High Stakes Human Systems Integration. … International
Conference and Workshop on Enterprises as Systems. Northern Illinois University.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_facnotes.docx
December 01, 2017 - Slide 1
Learning Objectives
SAY:
This module will help you develop a systems view of patient safety … These defects are as much a part of our health care systems as are the innovations. … Errors also occur because systems frequently are not designed to catch mistakes before they reach the … When we focus on systems, rather than individuals, we realize that we can redesign care and delivery … What systems may have led to the events?
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-facilitator-guide.docx
May 01, 2017 - Learning systems; and
5. Accountability and justice. … To achieve optimal outcomes, organizations must design robust systems that minimize risks. … Forcing functions, checks, and redundancies are some features of systems intended to minimize the risk … Slide 20
SAY:
Learning systems
By establishing learning systems, organizations can manage both systems … In contrast, a Just Culture environment will support improved outcomes by emphasizing both robust systems
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4e_combo_psi08-postophipfx-bestpractices.pdf
May 20, 2016 - Additional Resources
Systems/Processes
• Agency for Healthcare Research and Quality. … /hospital/fallpxtoolkit/index.html
http://www.ahrq.gov/professionals/systems/long-term-care/resources … /injuries/fallspx/fallspxmanual.pdf
http://www.ahrq.gov/professionals/systems/long-term-care/resources … /injuries/fallspx/fallspxmanual.pdf
http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/ … Bloomington, MN: Institute for Clinical Systems Improvement; April 2012.
https://www.icsi.org/_asset/
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www.ahrq.gov/sites/default/files/2024-11/golden-west-report.pdf
January 01, 2024 - To identify preferred priorities for implementation of patient safety reporting systems
3. … The group discussed
error reporting systems, the kinds of errors that should be reported, and how the … • To identify preferred priorities for implementation of reporting systems. … A just culture supports open discussion of medical error to improve care delivery
systems. … He holds a degree in mechanical systems
engineering and a juris doctor.
Frederick J.
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/section-6-table-2-3.pdf
June 05, 2025 - Malignancy ≥ 1 claim ≥ 1 claim ≥ 1 claim
Other ≥ 1 claim per
body system for 2
different body
systems … during
the measurement
period*
≥ 2 claims per
body system for 2
different body
systems during … the measurement
period*
≥ 1 claim per body
system per year
for 2 different
body systems
during
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www.ahrq.gov/sites/default/files/2024-01/malone-report.pdf
January 01, 2024 - Electronic prescribing (e-prescribing) and pharmacy information systems include DDI alerts as a
form … The second approach described in the literature was a systematic assessment
of DDIs for CDS systems … seriousness in order to simplify and increase the consistency of these classification
systems. … is dynamic and will evolve as systems become more
sophisticated. … Development of a context model to prioritize drug safety alerts in CPOE systems.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-about-cusp.pptx
May 01, 2017 - Care
15
Managing Error and Risk3
16
Learn About CUSP
AHRQ Safety Program for Perinatal Care
16
Systems … Work Together
To Improve Outcomes3
17
Learn About CUSP
AHRQ Safety Program for Perinatal Care
17
Systems … Work Together
To Improve Outcomes3
18
Learn About CUSP
AHRQ Safety Program for Perinatal Care
18
Systems … Work Together
To Improve Outcomes3
19
Learn About CUSP
AHRQ Safety Program for Perinatal Care
19
Systems … mental models
Expanded knowledge of potential
hazards and barriers to safety
Collaborative focus on
systems