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4341. Title Page (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r01hs015009-ward-final-report-2008.pdf
      January 01, 2008 - Methods The project made use of multiple methods for data collection and analyses. … higher progress ratings in urban hospitals were related to intensivist staffing, preventing wrong-site procedures … Based on their feedback, we plan to add folders for policies and procedures. … Systematic Review of Cost Methods. … HIT Interest Group members shared approaches and recommendations and discussed approaches for secure back-up

4342. Appendix B: Risk Assessment Models, Protocols, and Order Sets | Agency for Healthcare Research and Quality
      ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/vtguide/appb.html
      October 01, 2022 - Challenges in implementing government-directed VTE guidance for medical patients: a mixed methods study … //www.ahrq.gov/patient-safety/settings/hospital/vtguide/appb.html   Back

4343. In Conversation With…Kaveh G. Shojania, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
      September 01, 2011 - The VA has done a very good job with getting back to the reporter. … about what makes a good incident reporting system, it sounds like obviously a very strong follow-up procedure … For measuring the actual incidence of safety events, other detection methods are more sensitive, including … errors, are currently addressed through morbidity and mortality conferences and hospital credentialing procedures … The actions that hospital leaders take in response to reports teach providers whether the time and risks

4344. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please | PSNet
      psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
      September 01, 2011 - For measuring the actual incidence of safety events, other detection methods are more sensitive, including … errors, are currently addressed through morbidity and mortality conferences and hospital credentialing procedures … The actions that hospital leaders take in response to reports teach providers whether the time and risks … The VA has done a very good job with getting back to the reporter. … about what makes a good incident reporting system, it sounds like obviously a very strong follow-up procedure

4345. 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.pdf
      November 01, 2019 - An overview of the data collection methods for OneKey and AHA can be found in the Compendium of U.S. … When using the list, users should bear in mind a few caveats and limitations to the current methods … The sources use different data collection methods; also, AHA data were from 2017, whereas those from … of LI Headings Rule Name Status Description Appropriate nesting Passed Appropriate nesting Back

4346. Comparative Health System Performance Initiative: Compendium of U.S. Health Systems, 2018, Hospital Linkage File, Technical Documentation (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/2018-hospital-linkage-techdoc-cx.pdf
      January 01, 2018 - An overview of the data collection methods for OneKey and AHA can be found in the Compendium of U.S. … When using the list, users should bear in mind a few caveats and limitations to the current methods … The sources use different data collection methods; also, AHA data were from 2017, whereas those from … of LI Headings Rule Name Status Description Appropriate nesting Passed Appropriate nesting Back

4347. Do Not Miss Sepsis Needles in Viral Haystacks! | PSNet
      psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
      March 27, 2024 - On day 3 after the first ED visit, the child was brought back to the ED by ambulance with pulseless electrical … educating clinicians about cognitive biases, their potential contribution to diagnostic errors, and methods … implement conscious consideration of alternative diagnoses, may also have some efficacy. 33,34 These methods … Methods Inf Med . 2019;58(S 02):e43-e57. [ Available at ] Ackermann K, Baker J, Green M, et al. … December 9, 2020 Using an online quiz-based reinforcement system to teach healthcare

4348. 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 - An overview of the data collection methods for OneKey and AHA can be found in the Compendium of U.S. … When using the list, users should bear in mind a few caveats and limitations to the current methods … The sources use different data collection methods; also, AHA data were from 2017, whereas those from … of LI Headings Rule Name Status Description Appropriate nesting Passed Appropriate nesting Back

4349. 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

4350. Additional Patient Outcomes and Alternative Pathways in Evaluations of Testing | Effective Health Care (EHC) Program
      effectivehealthcare-admin.ahrq.gov/products/outcomes-testing-evaluation/research
      January 01, 2019 - & Tools Research Methods & Tools Tools & Software Education Resources About … anxiety and distress among patients prior to their examination. 13 Any test that influences the rate or method … Prenatal testing provides another useful illustration of the emotional effects of procedures following … effects of testing discussed here, and they may miss other issues such as stigma, reassurance, or ease of procedure … effectivehealthcare.ahrq.gov/products/outcomes-testing-evaluation/research   Back

4351. Improving Communication and Teamwork in the Surgical Environment Module: Facilitator Notes | Agency for Healthcare Research and Quality
      ce.effectivehealthcare.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/improving-fac-notes.html
      May 01, 2017 - Healthcare-Associated Infections Program Combating Antibiotic-Resistant Bacteria About the CUSP Method … Then we will discuss these methods to improve teamwork and communication: Briefings Debriefings … This is of great importance in procedures that are side specific. … labeling by reading back the patient’s name to ensure specimens are properly processed. … Here, closed loop is called by its other name – check-back.

4352. TeamSTEPPS Fundamentals Course: Module 4. Leading Teams | Agency for Healthcare Research and Quality
      pbrn.ahrq.gov/teamstepps/instructor/fundamentals/module4/igleadership.html
      March 01, 2019 - Establishment of a method to formally change the existing plan to incorporate lessons learned. … Upton lead the Labor and Delivery Team debrief immediately following a procedure.     … www.ahrq.gov/teamstepps/instructor/fundamentals/module4/igleadership.html   Back

4353. TeamSTEPPS Fundamentals Course: Module 4. Leading Teams | Agency for Healthcare Research and Quality
      pcmh.ahrq.gov/teamstepps/instructor/fundamentals/module4/igleadership.html
      March 01, 2019 - Establishment of a method to formally change the existing plan to incorporate lessons learned. … Upton lead the Labor and Delivery Team debrief immediately following a procedure.     … www.ahrq.gov/teamstepps/instructor/fundamentals/module4/igleadership.html   Back

4354. Ensuring Safe Performance of Electronic Health Records - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r01hs023696-bates-final-report-2019.pdf
      January 01, 2019 - Methods: To further refine and develop the tool, we continuously updated the content by keeping up … We developed a method for testing EHR systems in actual operation that can support learning through … and use this information to improve the critical safety aspects of their EHR systems and feed it back … functionality and continually improve and optimize the safety performance of their EHR systems.8 This testing method … METHODS Study Design To update and further develop the tool, we used the existing software platform

4355. Final Progress Report: ESDP in Community Hospitals (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/22923-Holland-report.pdf
      April 30, 2016 - study at MCHS-EC, the DP policy applied to Social Services and Case Management, and the Discharge Procedure … METHODS Study Design. … Data Sources/Collection Procedures. … Data Collection Procedures. … On enrollment, patients and clinicians were asked whether the patient would be discharged back home

4356. Final Progress Report: ESDP in Community Hospitals (pdf file)
      preventiveservices.ahrq.gov/sites/default/files/2024-01/holland-report.pdf
      January 01, 2024 - study at MCHS-EC, the DP policy applied to Social Services and Case Management, and the Discharge Procedure … METHODS Study Design. … Data Sources/Collection Procedures. … Data Collection Procedures. … On enrollment, patients and clinicians were asked whether the patient would be discharged back home

4357. Final Progress Report: ESDP in Community Hospitals (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/holland-report.pdf
      January 01, 2024 - study at MCHS-EC, the DP policy applied to Social Services and Case Management, and the Discharge Procedure … METHODS Study Design. … Data Sources/Collection Procedures. … Data Collection Procedures. … On enrollment, patients and clinicians were asked whether the patient would be discharged back home

4358. References | Agency for Healthcare Research and Quality
      ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state-references.html
      January 01, 2024 - Methods 3. Results 4. Discussion References Appendix A. Search Terms Appendix B. … Med Teach 2019;41(5):517-524. https://pubmed.ncbi.nlm.nih.gov/30244625/ . … Exploring telediagnostic procedures in child neuropsychiatry: addressing ADHD diagnosis and autism symptoms … Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation. … diagnostic-safety/resources/issue-briefs/dxsafety-current-state-references.html   Back

4359. Overview of Patient Safety Learning Laboratory (PSLL) Projects | Agency for Healthcare Research and Quality
      pbrn.ahrq.gov/patient-safety/resources/learning-lab/index.html
      February 01, 2024 - Tools included process mapping, swim lane diagrams, functional resonance analysis method, failure modes … Develop a systematic method to study patient safety using a stepwise approach of problem analysis through … assess patients’ understanding of their diagnosis at optimal times so their feedback can be relayed back … neonatal resuscitation: (1) the design of the physical workspace; (2) decision making during this invasive procedure … factors such as religiosity and spirituality; and 2) design and implement educational interventions to teach

4360. Overview of Patient Safety Learning Laboratory (PSLL) Projects | Agency for Healthcare Research and Quality
      pcmh.ahrq.gov/patient-safety/resources/learning-lab/index.html
      February 01, 2024 - Tools included process mapping, swim lane diagrams, functional resonance analysis method, failure modes … Develop a systematic method to study patient safety using a stepwise approach of problem analysis through … assess patients’ understanding of their diagnosis at optimal times so their feedback can be relayed back … neonatal resuscitation: (1) the design of the physical workspace; (2) decision making during this invasive procedure … factors such as religiosity and spirituality; and 2) design and implement educational interventions to teach