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321. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
     April 02, 2008 - Methods This descriptive study used content analysis of 16 randomly selected videotapes taken at … • Stage 5: Surgical procedure. • Stage 6: Infant resuscitation. … team expanded considerably, and leadership transferred from surgeon to anesthesiologist (or CRNA) and back … The exchange of leadership from MD/OB to anesthesiologist or CRNA and back, the initiation of the surgical … www.air.org/teams/publications/MTT/AIR_Lit_Review.pdf Abstract Background Concepts and Framework Methods

322. 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 - n Third, choose a formal method for improvement. … He arranged for General Electric (GE) to teach 45 employees the methods of Lean and Six Sigma. … to the old method. … dictate the time of day that new patients would no longer be transferred to the ASU, as well as the procedure … Butler procedures, timelines, expectations 3.

323. Section 2. Implementing Recommendations in Academic Curricula | Agency for Healthcare Research and Quality
     www.ahrq.gov/cpi/centers/ockt/kt/tools/impuspstf/impuspstf2.html
     June 01, 2022 - Students leave the wards 3 times during the third year and go back to the classroom to focus on cross-cutting … The information used and methods employed to achieve shared informed decision making vary widely, ranging … Because of the high rate of false-positive results, many patients will undergo invasive diagnostic procedures … Although the morbidity and mortality rates from these procedures in asymptomatic individuals are not

324. Surgical Complication Prevention Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/guide-surgcomp.pdf
     December 01, 2017 - changes procedural aspects of care that can be explicitly defined, such as surgical skin preparation procedures … You may find this method simpler than developing a formal data collection strategy that often requires … When we took this patient’s story back to our perioperative staff, they were moved. … Other industries teach us that there are clear principles of safe system design, including the following … Evaluation methods can be formal or informal.

325. Final Progress Report: The National Quality Forum Annual Meeting 2004 (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/kizer2-report.pdf
     January 01, 2025 - , and data display methods. … instead of lidocaine 1% with epinephrine 1:100,000 (0.01 mg) at the inception of a routine surgical procedure … The settlement agreement required the hospital to teach others about the possibility of errors from … , but we should be selective (for example, coronary bypass surgery) and other outcomes in similar procedures … outcomes should be selective (e.g., coronary bypass surgery) and then the outcomes in other similar procedures

326. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/crane.html
     August 01, 2017 - this information useful to correct errors, near-miss reporting will be unlikely to become a routine procedure … Methods. … Methods We recruited seven diverse practices to participate in the 1-year pilot project. … a “charter” outlining the problem to be addressed, expected outcomes, and a timeframe for reporting back … Consultation on research methods and analytic support was provided by Generativity LLC.

327. Strategy 3: Nurse Bedside Shift Report Implementation Handbook (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.pdf
     August 01, 2010 - tri-fold checklist provides information about how to fold the brochure by indicating the front and back … As needed, identify alternative methods or outlets for nurses to talk with one another. … To help clarify these situations for staff nurses, your hospital may want to establish procedures for … Often, if bedside shift report is not consistently monitored, nurses may revert back to familiar habits … In March 2009, the three nurse champions attended a course focusing on quality improvement methods

328. Final Progress Report: Short-term Clinical Deterioration After Acute Pulmonary Embolism (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/weekes-report.pdf
     January 01, 2025 - METHODS: We used prospective registry data from six EDs. … clinical algorithms,1,7,13–16 and some meta-analyses now support use of one or multiple RV assessment methods … Second, we determined which of these right ventricular assessment methods best improved the prognostic … Method Sensitivity Specificity Positive Predictive Value Negative Predictive Value AUC PE Score … of LI Headings Rule Name Status Description Appropriate nesting Passed Appropriate nesting Back

329. Final Progress Report: Enhancing Stroke Prehospital and Emergency Evaluation and Delivery (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/prabhakaran-holl-report.pdf
     January 01, 2025 - Methods Natural language processing (NLP) retrospective analysis of Emergency Medical Services (EMS) … Methods Aim 1 • Retrospective Secondary Data Analysis: We used NLP to extract textual and discrete … • List 1st Call Telestroke MD AND a "back-up" Telestroke MD • Implementation: During LC #4, implementation … Methods 6. Results 7. List of Publications and Products

330. The National Action Alliance to Advance Patient Safety Summer Webinar Series - PowerPoint Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/public-action-alliance-slides-040323_LOCKED.pdf
     May 25, 2023 - hospitalized improved for: ► acute myocardial infarction, ► heart failure ► pneumonia ► major surgical procedures … Safety current state 2) Establish Group Rules - Check your Ego at the Door 3) Establish Purpose - All Teach … at te m pt s Fa lls C LA BS I M R SA B ac te re m ia Leadership Safety culture All teach … Description Recommended Actions 7–11 Just Beginning • Create an action plan for and use improvement science methods … highly encouraged • Provided 2.5hour workshops for all managers, expert facilitator • What we heard back

331. Situation Monitoring: Severe Hypertension (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_4-situation-monitoring-speaker-notes.pdf
     July 01, 2023 - In this module we teach you about briefs, huddles, and debriefs. … Are we confirming the receipt of information and clarifying uncertainties with a check‐back? … Did team members check‐back on communications? … Did everyone check‐back or close‐the‐loop to confirm messages were correctly understood? … independent thought, inclusion, and prompted discussion of both opportunities for improvement and viable methods

332. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_overview_impmodel.pptx
     December 01, 2017 - National improvement effort for hospitals of all sizes and any surgical procedure type Designed to reduce … SSIs and other surgical complications for any procedure type Overview ‹#› AHRQ Safety Program … Program will teach you to embed adaptive work (CUSP) in your technical work (surgical care) Unlike other … If, so what data collection method was used? Survey? Interviews? Focus groups? Alternative method? … Take these steps back to your team and complete the premortem exercise during your first surgical safety

333. Slide 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/connecting-dots-100813.ppt
     January 01, 2013 - ; teach new skills to guide behavior The Role of Organizational Culture Safety Culture4 A cross … Allows us to make sense of environment Reflects common language… is heard and observed Leaders create/teach … Methods: We performed multiple regressions to examine the relationships between 15 patient safety culture … Knowingly violated safe procedures? Pass substitution test? … positive role model Create structures consistent with new way of thinking/working/behaving…policy/procedure

334. Final Progress Report: Connected Emergency Care (CEC) Patient Safety Learning Lab (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/hinson-levin-report.pdf
     January 01, 2025 - Key activities included focus groups, task analysis, process mapping, and critical decision method interviews … Finally, informed by all the activities above, we performed case-based critical decision method interviews … During our critical decision method interviews, we learned that less than 20% of ED clinicians were … 10/2023 The Super Learner Ensemble: a Powerful Artificial Intelligence-Based Predictive Modeling Method … of LI Headings Rule Name Status Description Appropriate nesting Passed Appropriate nesting Back

335. AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Enhancing Teamwork and Leadership (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-teamwork-leadership-2025.pdf
     January 01, 2025 - capture communication, leadership, and cognitive load differences more precisely than traditional methods … ■ A simulation-based intervention created to teach physicians and nurses about team-based error disclosure … workplace safety among nonhealthcare organizations; and (4) conduct a detailed literature review of methods … : A final report was not provided, but an article about the project (Mayer et al., 2011) describes methods … Key Findings/Impact: Researchers designed a simulation-based intervention to teach physicians and nurses

336. Final Progress Report: Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/catchpole2-report.pdf
     January 01, 2025 - Results: We identified medication icon labels as a method to improve awareness; a syringe holder hub … anesthesia suites may be ‘small, dark, and cramped’ with restricted access to patients during some procedures … Design Systems Modelling Systems analysis is an important method for understanding how success or failure … DELIVERY: Syringe Hub The current organizational method in many institutions is to make do with what … of LI Headings Rule Name Status Description Appropriate nesting Passed Appropriate nesting Back

337. 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 - barrier to standardizing prevention and treatment of VAP is that the radiological and microbiological methods … 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. … Comparison of usual and alternative methods to measure height in mechanically ventilated patients:

338. Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/module4_pu-implementation.docx
     June 02, 2025 - Share a written plan to communicate pressure injury risk procedures with the new member. … ASK: How will you make sure temporary staff are trained in pressure risk procedures? … Slide 28 SAY: Close the information loop by having the Implementation Team report back to the Unit … First, adult learning theory suggests that adults learn best through methods that build on their own … Options include didactic methods, such as lectures, interactive presentations, online lessons, case study

339. Puh-Erepguide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-erepguide.docx
     February 10, 2014 - Pressure Ulcer Healing Electronic Reports This training will provide you with the information you need to teach … Ulcer Location Code Ulcer Location Description HEAD Back of head EAR Ear: R/L SCAP Scapula: … aspect or per clock method [12 to 6 o’clock]) as recorded in centimeters. … This is the measurement of the ulcer length using the facility’s method (i.e., either at longest aspect … or per clock method [12 to 6 o’clock]) recorded in centimeters.

340. Final Progress Report: Implementing a Program of Patient Safety in Small, Rural Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/jones-report.pdf
     January 01, 2024 - processes include selecting an appropriate survey instrument, using effective and unbiased data collection procedures … Inappropriate sampling, bias in data collection procedures (such as administering the survey in a group … This sampling procedure was repeated 1,000 times with replacement, and logistic regression was conducted … Qualitative research methods for the social sciences. … Mail and internet surveys: The tailored design method.