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1361. Final Progress Report: TIPI Systems To Reduce Errors in Emergency Cardiac Care (pdf file)
      www.ahrq.gov/sites/default/files/2024-12/selker-report.pdf
      January 01, 2024 - of LI Headings Rule Name Status Description Appropriate nesting Passed Appropriate nesting Back

1362. 050-Dec-Implementation-Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/050-dec-implementation-notes.docx
      October 01, 2024 - (4) Right leg and foot (5) Left leg and foot. (6) Back of neck, back, then the buttocks. … Working with Infection Prevention, they gather unit data going back 12 months and calculate estimates

1363. Toolkit for Reducing CAUTI in Hospital Units: Implementation Guide (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/implementation-guide_0.pdf
      September 01, 2015 - Use audits and observations of practice and ensure that collected data are reported back to staff doing … Use case scenarios to teach best use of the nurse-driven protocol for removal of catheters. … Reducing CAUTI in Hospitals Implementation Guide 21 Teach

1364. Toolkit for Reducing CAUTI in Hospital Units: Implementation Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide.pdf
      September 01, 2015 - Use audits and observations of practice and ensure that collected data are reported back to staff doing … Use case scenarios to teach best use of the nurse-driven protocol for removal of catheters. … Reducing CAUTI in Hospitals Implementation Guide 21 Teach

1365. Barriers Associated with Medication Information Handoffs (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Bayley.pdf
      January 01, 2004 - detailed care process maps that documented the flow of information from ambulatory to acute care and back … Efforts are underway to teach patients how to keep themselves safe and to be reliable conduits for medication

1366. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
      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 - patient’s anticoagulation flow sheet and noted the discrepancy between the patient’s status as being back

1367. Final Progress Report: Creation and validation of a training toolkit to ensure safe and proficient use of EHR by medical scribes (pdf file)
      www.ahrq.gov/sites/default/files/2024-05/gold-report.pdf
      January 01, 2024 - Member checking is accomplished by going back to key informants to confirm that the study findings are

1368. Final Progress Report: ESDP in Community Hospitals (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/holland-report.pdf
      January 01, 2024 - On enrollment, patients and clinicians were asked whether the patient would be discharged back home

1369. From Public Testimony to Vehicle for Statewide Action: Experience of the Michigan State Commission on Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Valade_46.pdf
      May 05, 2008 - safety standards are established across the continuum of care so that years from now, Michigan can look back

1370. Low Tidal Volume Ventilation Guide for Reducing Ventilator-Associated Events in Mechanically Ventilated Patients (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-mvpguide.pdf
      January 01, 2017 - Other critical industries, like airlines and nuclear energy, teach us clear principles of safe system … defects, we need a shift in perspective—an attitude that errors and near misses have something to teach … To accomplish this, we recommend that you monitor and report back to your staff each month.

1371. Patient Safety Amid Nursing Workforce Challenges | PSNet
      psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
      April 24, 2024 - I also teach at the University of Maryland School of Nursing in their nursing leadership courses.

1372. In Conversation with...Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges | PSNet
      psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
      April 24, 2024 - I also teach at the University of Maryland School of Nursing in their nursing leadership courses.

1373. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853902/psn-pdf
      September 27, 2023 - cultural and language barriers with patients, communication barriers between doctors, and lack of back-up

1374. Final Progress Report: Utility of Predictive Systems in Diagnostic Errors (UPSIDE) (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/auerbach-report.pdf
      January 01, 2025 - of LI Headings Rule Name Status Description Appropriate nesting Passed Appropriate nesting Back

1375. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning | PSNet
      psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
      January 29, 2021 - , cultural and language barriers with patients, communication barriers between doctors, and lack of back-up

1376. Comparative Health System Performance Initiative: Compendium of U.S. Health Systems, 2018, Hospital Linkage File, Technical Documentation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/2018-hospital-linkage-techdoc-cx.pdf
      January 01, 2018 - of LI Headings Rule Name Status Description Appropriate nesting Passed Appropriate nesting Back

1377. Challenges to Real-Time Decision Support in Health Care (pdf file)
      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 - strategies to achieve lifesaving interventions expeditiously and allow less essential processes to be held back

1378. Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
      May 05, 2008 - high-reliability organizations to utilize structured communication techniques, such as checklists and “read-back

1379. Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/ptflowguide.pdf
      January 01, 2014 - He arranged for General Electric (GE) to teach 45 employees the methods of Lean and Six Sigma. … Since the WOWs were not in place until February 2010, progress was held back during the early phases … Finally, data can be used to feed information back to staff, so that they can see the impact of their … as a “flavor of the month,” where operations would be modified for a while but would slowly revert back … transferred to the ASU, as well as the procedure for transferring existing ED patients in the ASU back

1380. Final Progress Report: Caregiver innovations to reduce harm in Neonatal Intensive Care (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/thomas-report.pdf
      January 01, 2025 - collection (embedding) by (1) building from the Causal Loop Diagram (CLD) to the simulation and then back … of LI Headings Rule Name Status Description Appropriate nesting Failed Appropriate nesting Back