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digital.ahrq.gov/ahrq-funded-projects/ambulatory-electronic-medical-record-and-shared-access
January 01, 2023 - Ambulatory Electronic Medical Record and Shared Access
Project Final Report ( PDF , 305.67 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ…
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psnet.ahrq.gov/node/49565/psn-pdf
July 01, 2008 - Wrong Route for Nutrients
July 1, 2008
Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wrong-route-nutrients
The Case
An 82-year-old man living in a skilled nursing facility (SNF) had not been eating or drinking well for about 6
months. He had lost weight and d…
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www.ahrq.gov/nursing-home/materials/staffing.html
June 01, 2021 - Staffing During the COVID-19 Pandemic: A Guide for Nursing Home Leaders
This resource guide from the Project ECHO and IHI Teams was written by and for directors of nursing, administrators, and other nursing home leaders. It outlines steps to reduce or eliminate urgent staff shortages, particularly shortages of …
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www.ahrq.gov/teamstepps-program/curriculum/implement/teach.html
January 01, 2024 - Teaching Implementation Planning
Present Slide 22, "Implementation Planning"; use this slide to transition to implementation planning. Note that you need to consider measurement when implementing TeamSTEPPS, but it is not the only thing. Explain that implementation planning will equip trainees with a 10-s…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
June 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case June 2004
The Wrong Shot:
Error Disclosure
Source and Credits
This presentation is based on the June 2004
AHRQ WebM&M Spotlight Case in Pediatrics
CME credit is available through the Web site
See the full article at http://webmm.ahrq.gov
Commentary by: Thomas H. …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement/pf-engagement-facnotes.docx
May 01, 2017 - including having information explained fully and clearly and receiving an explanation and apology if things … family understand the health condition, procedure, and next steps in their care by checking to see if things
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www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/2018hospitalsopsreport.pdf
March 01, 2018 - Organizational Learning—Continuous Improvement
We are actively doing things to improve
patient safety … Handoffs & Transitions
Things “fall between the cracks” when
transferring patients from one unit to … Organizational Learning—Continuous Improvement
A6 We are actively doing things to improve
patient … We are actively doing things to improve
patient safety.
84% 84% 0% 20% -29% 4% -4%
A9 2. … Things “fall between the cracks” when
transferring patients from one unit to
another.
42% 42% 0%
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2018hospitalsopsreport-rev0921.pdf
March 01, 2018 - Organizational Learning—Continuous Improvement
We are actively doing things to improve
patient safety … Handoffs & Transitions
Things “fall between the cracks” when
transferring patients from one unit to … Organizational Learning—Continuous Improvement
A6 We are actively doing things to improve
patient … We are actively doing things to improve
patient safety.
84% 84% 0% 20% -29% 4% -4%
A9 2. … Things “fall between the cracks” when
transferring patients from one unit to
another.
42% 42% 0%
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_5-mutual-support.pptx
July 01, 2023 - Offer up specific examples of things that drew your attention. … Using “I” statements will help you underscore the point that you are simply explaining things from your
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_5-mutual-support-speaker-notes.pdf
July 01, 2023 - Offer up specific examples of things that drew your attention. … Using “I”
statements will help you underscore the point that you are simply explaining
things from
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psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
March 27, 2024 - It may recommend movies to me, or things to buy at the grocery store, but it doesn’t always get that … We all want the grand slam solution for making patients better, but there are also so, so many small things
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psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
March 27, 2024 - It may recommend movies to me, or things to buy at the grocery store, but it doesn’t always get that … We all want the grand slam solution for making patients better, but there are also so, so many small things
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/actionplan-trip-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Action Plan for Translating Research Into Practice: Gap Analysis and Tests of Change
SAY:
This module will cover the Translating Research Into Practice (TRIP) framework. The TRIP framework lets us dig…
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psnet.ahrq.gov/web-mm/room-without-orders
September 01, 2011 - SPOTLIGHT CASE
A Room Without Orders
Citation Text:
Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3…
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs021290-agha-final-report-2017.pdf
January 01, 2017 - might be helpful… someone who is kind of sitting there with you and helping you find short cuts
to the things
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/pfepc-fullguide-final508.pdf
April 01, 2018 - write down an agenda.6,7
“The Note Sheet helps to
decrease the number of calls
after the visit for things … “I’ve been doing this [primary
care] for a long time and
didn’t realize a lot of things
are not heard … patient outcomes,
and patient and clinician satisfaction.19,20
“Sometimes during a warm
handoff things … Establish evaluation measures
There are several things to consider when selecting measurements to assess
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3_communication.pptx
July 01, 2023 - OK, there are a few things we can do. Please continue to monitor carefully. … To close the loop, as you'll learn next, the doctor may reply, “OK, there are a few things we can do. … Sonentag is on his way, and we are working towards getting things under control. … Sonnentag is on his way, and we are working towards getting things under control.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3-communication-speaker-notes.pdf
July 01, 2023 - OK, there are a few
things we can do.
Please continue to
monitor carefully. … To close
the loop, as you'll learn next, the doctor may reply, “OK, there are a few things we can
do … Sonentag is on his
way, and we are working towards
getting things under control. … Sonnentag is on his way,
and we are working towards getting things under control.
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effectivehealthcare.ahrq.gov/health-topics/memory
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www.ahrq.gov/sites/default/files/2025-03/mcfarland-report.pdf
January 01, 2025 - determine the causes of
a patient safety error
2.16 0.60 0% 0% 26% 63% 11%
Most errors are due to things … Most errors are due to things that
clinicians can’t do anything about. … Facilitating Factors Things that are working well or could be improved to support more
effective functioning