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181. Final Progress Report: Cook County & Rush Developmental Center for Research in Patient Safety: Diagnosis Error Evaluation and Research (DEER) Project (pdf file)
     www.ahrq.gov/sites/default/files/2025-04/schiff-mcnutt-report.pdf
     January 01, 2025 - To overcome these limitations, our team sought to develop a more systematic method for examining cases … of hypothyroidism, we downloaded TSH results during 2000 and 2001 for all inpatient and outpatient procedures … One patient with back pain was initially dismissed, labeled as an ED “frequent flyer.” … surprisingly rare, perhaps <1/50,000 ED visits for chest pain and likely an equally rare cause for back … Developing a national action agenda for the National Health Information Infrastructure: Report back

182. Resident Physicians as Safety Champions | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/phys-championsgd/section5.html
     October 01, 2015 - In addition to learning disease management and methods to optimize clinical outcomes, RPs are expected … The RP can— Use the check-back method to verify and validate information is exchanged in the way … S/he will maintain situation awareness during the CVC insertion, stop the procedure if there is a break … Compliance with all of the steps to ensure that the procedure is done aseptically is very important to

183. Final Progress Report: Diagnostic Error in Medicine Annual Conference (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/singh2-report.pdf
     January 01, 2025 - Methods: The conference is a 2.5-day meeting preceded by half-day pre-conference sessions and a patient … For example, Croskerry has proposed that cognitive training methods might decrease the rate of diagnostic … • Quality Improvement Session: “Your Results are Back” – Identifying Gaps and Improving the Follow-up … Sessions • Patient Summit • Research Summit (invitation only) • Short Courses: o Training Others to Teach … Conference 12 AHRQ Grant Final Progress Report Title Page Structured Abstract Purpose Scope Methods

184. Final Progress Report: Improving Patient Safety in Orthopedic Trauma Surgical Training (pdf file)
     www.ahrq.gov/sites/default/files/2024-04/anderson-report.pdf
     January 01, 2024 - An expert faculty from across the U.S. is assembled to teach the course, affording us additional opportunities … The path to the lower left corner is enabled by the mirror at the center back that redirects half of … movement is sufficiently large that it is unlikely that the learner can feel the harder material at the back … If the back edge cannot be felt while drilling, it may be sufficient to simply provide enough material … The second was the time to conduct the procedure. Figure 9.

185. Resident Sign-Out: A Precarious Exchange of Critical Information in a Fast-Paced World (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Borowitz_4.pdf
     January 22, 2008 - Methods: Between October 2005 and February 2006, and again between October 2006 and February 2007, residents … Additional studies are also needed to identify how to best teach and evaluate a physician’s ability … Methods Scope and Study Population The Institutional Review Board of the University of Virginia approved … night shift meet with other members of the team to review what happened overnight and to hand-off care back … system **CareCast = computerized results and document repository 21 Abstract Introduction Methods

186. Implementation and Impacts of Lean Redesigns in Primary Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/delivery-initiative/leanprimarycarewebinar.html
     December 01, 2017 - Qualitative Analytic Methods Slide 9. Measures of Implementation Slide 10. … Quantitative Methods Slide 20. Phased Implementation of Lean Redesigns Slide 21. … Methods Research Report. … from the patient service representative, to the doctor and everyone in between, and you not only get back … Return to Contents   Slide 19 Quantitative Methods Data sourced from dashboards, billing

187. Compendium of U.S. Health Systems, 2022, Hospital Linkage File, Technical Documentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/2022-hospital-linkage-techdoc-021224.pdf
     January 01, 2022 - An overview of the data collection methods for the OneKey and AHA data can be found in the Compendium … When using the linkage file, users should bear in mind a few caveats and limitations to the current methods … characterization of hospitals and their linkages to systems (for example, they use different data collection methods … of LI Headings Rule Name Status Description Appropriate nesting Passed Appropriate nesting Back

188. CUSP: A Framework for Success (Transcript) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/content-calls/framework.html
     April 01, 2013 - Instructions will be given as to the procedure to follow if you’d like to ask a question. … in 2008 that allows you to drive down at a very specific level to understand the method for translating … We create policies and processes and procedures. … A commitment to rigorous measurement, to standardization, to scientifically sound methods of improvement … We have to teach people to do perineal cleansing before they put catheters in."

189. Final Progress Report: Developing a Risk Index of Healthcare Provider Alertness To Improve Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/landrigan3-report.pdf
     January 01, 2024 - Methods: A circadian (internal timekeeping) model and a linked human performance model were used to … For example, our published circadian adjustment method uses schedule information in conjunction with … Improved procedures for summarizing performance were added specifically to analyze the resident schedules … In addition to the direct effect to physician trainees and their patients, the methods developed in … version one but does not give the interns as much time to adjust to night work and makes them shift back

190. Final Progress Report: Risk Assessment of Pediatric Emergency Transfers (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/holl-report.pdf
     January 01, 2025 - Methods: Risks were assessed using a prospective risk analysis method, Failure Mode Effects and Criticality … research conducted in healthcare setting that provides what a handoff is, how to perform it, and how to teach … METHODS D.1. Study Design D.1.1. … Out of hospital Intravenous Access: Unnecessary Procedures and Excessive Cost. … of LI Headings Rule Name Status Description Appropriate nesting Passed Appropriate nesting Back

191. Improving Nonsurgical Management of Urinary Incontinence in Women (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/projects/urinary/managing-urinary-incontinence-slides.pdf
     October 14, 2022 - Improvement and Implementation Science) ► Multilevel Interventions ► Agile Implementation ► Mixed Methods … Identify, Teach and Treat (IT2) Kimberly Kenton MD, MS, FACOG, FACS Arthur Hale Curtis Professor of … UI Resource Pocket Card Front and Back UI Information Sheet for Providers Front and Back … Project Goal Populations of Focus Project Features Patient Impact Provider Impact Identify, Teach

192. Compendium of U.S. Health Systems, 2023, Technical Documentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/2023-compendium-techdoc.pdf
     January 01, 2023 - Insurance Product Data and Methods Introduction This appendix describes the data and methods used … Nursing Home Data and Methods Introduction This appendix describes the data and methods used to construct … Home Health Care Organization Data and Methods This appendix describes the data and methods used to … Data Collection Methods D. Potential Misalignment of System Definitions E. … of LI Headings Rule Name Status Description Appropriate nesting Passed Appropriate nesting Back

193. Appendix A. Grantee Profiles | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/appa.html
     August 01, 2022 - As the final step, researchers pilot tested a customized TeamSTEPPS ® training designed to teach patients … and would be easy to use, they would be comfortable using the tools, and it would be beneficial to teach … Many patients have an incomplete understanding of the clinical procedures for which they must provide … were seeking input from others (65%), establishing the patient role in decisionmaking (53%), using teach-back … Complaints involving informed consent or SDM were more commonly associated with clinical procedures (

194. Final Progress Report: Using Team Simulation to Improve Error Disclosure to Patients and Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/gallagher2-report.pdf
     January 01, 2024 - Scope: We designed a simulation-based intervention to teach physicians and nurses about team-based error … Methods: We utilized a quasi-experimental pre-post intervention (38 physicians and 40 nurses) with control … METHODS This study was a quasi-experimental pre-post intervention with a control group. … participant’s initial abilities to plan and execute disclosure of a medical error using our detailed coding procedure … Patients prefer the method of "tell back-collaborative inquiry" to assess understanding of medical information

195. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/match.pdf
     August 01, 2012 - any medications you held for your procedure (test). … if errors are identified. 51 Examples of Metrics and Auditing Tools There are several effective methods … - back” method, also known as the “show-me” method or “closing the loop.”18 58 “Teach-back” is a … Patient understanding is confirmed when they explain it back to you. … These methods include the use of plain language, communication tools (e.g., multimedia), and “teach-back

196. Final Progress Report: Developing Best Practices for Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/baker-report.pdf
     January 01, 2024 - Results: The survey was implemented in Consortium hospitals, and results were reported back to hospitals … medication safety,89 patient safety initiatives range from anesthesia10 to patient restraint systems and procedures … safety, the implementation of that tool in a group of hospitals, reporting results from the project back … implementation of the PSCHO survey in Consortium hospitals produced data that we used both to report back … Due to the need to circle back and work on theoretical frameworks, the full empirical analysis is not

197. Final Progress Report: Proactive Risk Assessment of Primary Care of the Elderly (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/karsh-report.pdf
     January 01, 2024 - extremely important, and it consists of integrating care that takes place through referrals with different procedures … Neither the traditional HFMEA scoring method, which was developed for inpatient care, nor the traditional … beta-blocker and requires short-term hospitalization to stabilize -Cardiac cath -Short-term dialysis -Invasive procedure … -Sutures removed too soon after minor surgical procedure and wound dehiscence, which requires 6 weeks … there, has nothing, necessarily, to do with whether or not that failure is fixed. 11 The HFMEA method

198. 19-Perioperative-Teams (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/19-perioperative-teams.docx
     June 01, 2023 - Ensuring Access The information in this document is based on results from a Delphi panel (i.e., a method … Have a structured approach to learning Plan forward, reflect back, and act on the learning. … summary, through building a structured approach to learning, you will have a systematic way to reflect back

199. Final Progress Report: An Evaluation of the Effectiveness and Process Evaluation of a Rapid Response System (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lord-report.pdf
     January 01, 2024 - Methods: There were two 24-month study periods. … 26(27) 40(20) 66 Disposition Transfer to ICU 42(43) 89 (44) 131 Immediate treatment given trigger/s back … According to the nurses involved in the focus group, the RRS has improved the method of getting the … The implementation of an RRS not only is a change in protocols and procedures but also is a cultural … Additionally, the RRS serves as another method to provide teachable moments to the new house staff.

200. Sustaining Zero CLABSIs (Transcript) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/content-calls/zero-clabsi.html
     April 01, 2013 - I also reported back to the group who was missing data and for how much. … So it took us at that point back to the drawing board to say “Okay what's different now? … But that really was too easy, and so we needed to reeducate, ask for administrative assistance and back … have a NICU of course you want the parents in there, the grandparents want to come, so you need to teach … findings there as we work with hospitals within the Hospital Engagement Network, we will suggest CUSP as a method