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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects
AHRQ Safety Program for Perinatal Care
Sensemaking and Learn From Defects for Perinatal Safety
AHRQ Publication No. 17-0003-5-EF
May 2017
1
Learning Objectives
2
AHRQ Safety Program for Perinatal Care
Sen…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.html
July 01, 2023 - Sensemaking and Learn From Defects for Perinatal Safety
AHRQ Safety Program for Perinatal Care
Slide 1: AHRQ Safety Program for Perinatal Care
Sensemaking and Learn From Defects for Perinatal Safety
Slide 2: Learning Objectives
Image: Four ascending steps show the learning objectives:
Introduce …
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www.ahrq.gov/sites/default/files/2025-05/silber-report.pdf
January 01, 2025 - for acute myocardial infarction (AMI), congestive heart
failure (CHF), or pneumonia in the United … States during 2009-2011. … July 1, 2009, and November 30, 2011, at short-term acute care
hospitals within the 50 US states
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www.ahrq.gov/sites/default/files/publications/files/pfcases.pdf
August 01, 2014 - Research to conduct case
studies of three exemplary practice facilitation training programs in the United … States and describe
their formation, operation, and curricula. … program staff is led by three regional directors who oversee activities for a
particular region of the United … States: Colorado/Mountain, East and Southern Central time zone,
and Pacific and Northern Central time
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www.ahrq.gov/sites/default/files/wysiwyg/data/SyH-DR-PUF-Summary-Statistics-Medicare-Outpatient-Weighted.pdf
September 26, 2023 - Weighted Summary Statistics: PUF Medicare Outpatient File (Version 2)
15:39 Tuesday, September 26, 2023 1
Weighted Summary Statistics: PUF Medicare Outpatient File
Variable Variable Label
Count of
Non-missing
Values
(Unweighted)
Count of
Missing
Values
(Unweighted) Minimum Maximum Mean
Standard
Deviation
…
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www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide6.html
May 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism
Chapter 6. Track Performance with Metrics
Previous Page Next Page
Table of Contents
Preventing Hospital-Associated Venous Thromboembolism
Preface
Executive Summary
Chapter 1. The Framework for Improvement
Chapter 2. Analyze Care Delivery …
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www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide6.html
May 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism
Chapter 6. Track Performance with Metrics
Previous Page Next Page
Table of Contents
Preventing Hospital-Associated Venous Thromboembolism
Preface
Executive Summary
Chapter 1. The Framework for Improvement
Chapter 2. Analyze Care Delivery …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.pdf
April 01, 2011 - Strategy 4: IDEA Discharge Planning (Implementation Handbook)
Strategy 4: IDEAL Discharge Planning (Implementation Handbook)
Guide to Patient and Family Engagement
Care Transitions from
Hospital to Home:
IDEAL Discharge Planning
Implementation Handbook
Strategy 4: IDEAL Discharge Planning (Implementation …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Potter.pdf
January 01, 2003 - An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors
39
An Analysis of Nurses’ Cognitive Work:
A New Perspective for Understanding
Medical Errors
Patricia Potter, Laurie Wolf, Stuart Boxerman, Deborah Grayson,
Jennifer Sledge, Clay Dunagan, Bradley Evanoff
Abstract
He…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/sustainability-plan.pdf
June 01, 2021 - States Targeting Reduction in
Infections via Engagement program supplement.
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www.ahrq.gov/workingforquality/events/webinar-best-practices-to-improve-community-health.html
November 01, 2016 - Nazleen Bharmal, Director of Science and Policy from the Office of the Surgeon General of the United … States, will share some of the Office of the Surgeon General's priorities related to community health … I'm the Director of Science and Policy at the Office of the Surgeon General of the United States.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/McNeill.pdf
January 01, 2004 - The first annual program enrolled 51 participants from 15 States. … The second
program, which is currently underway, has approximately 60 participants from 21
States. … It has
made the case for such systems to a number of States. … Supporting States and other entities that pass patient safety
legislation is an important public policy … Should AHRQ concentrate its efforts on achieving similar results from multiple
States, or should it
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www.ahrq.gov/sites/default/files/publications2/files/takeheart-executive-summary.pdf
August 01, 2023 - recruitment priority for Partner Hospitals that serve
people living in the “Stroke Belt” within the US (states … A potential explanation for not meeting this priority may be that Stroke Belt states have
a relatively … Final Evaluation Report
12
no Medicaid coverage of CR in some states; Medicaid Advantage patients … referral to cardiac rehabilitation of patients
undergoing percutaneous coronary intervention in the United … States.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2015_cg_cahps_chartbook.pdf
January 01, 2015 - 963 66% 84% 84% 82%
Wisconsin 32,818 70% 88% 87% 87%
*When reporting comparison scores by State, States … 17,768 57% 91% 92% 82%
Wisconsin 4,667 71% 89% 93% 81%
*When reporting comparison scores by State, States … Database and therefore do not
constitute a representative sample of all medical practices in the United … States. … Bureau’s regions, based on the practice sites’ self-reported State and ZIP code information1.
1 States
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www.ahrq.gov/patient-safety/reports/hotline/design2.html
May 01, 2016 - examined instruments for collecting adverse events, errors, near misses, and unsafe conditions in the United … States and other countries and identified 27 consumer-enabled reporting systems and 14 survey tools … deployment (which was seen to have had limited effectiveness based on 5 years of experience in the United
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www.ahrq.gov/teamstepps-program/curriculum/communication/teach/two-day.html
December 01, 2023 - can be different from the intended meanings because of the context, backgrounds, and psychological states
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-learning-benchmarks.pdf
June 02, 2025 - TeamSTEPPS Learning Benchmarks
TeamSTEPPS Learning Benchmarks
Instructions: These questions focus on medical teamwork and communication and their effect
on quality and safety in patient care. For each of the following questions, please circle the
letter next to the one best answer.
1. A nurse is called t…
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www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/2021-hospital-linkage-techdoc-rev.pdf
January 01, 2021 - Health Systems, a list of health systems in the United States with details about their structure,
staffing … We then excluded 74 hospitals that were not located
in one of the 50 states or the District of Columbia … general acute care hospitals per system,
• Extent to which system hospitals are located in multiple States … Differences Across Data Sources
We attempted to maximize the coverage of hospitals in the United States … Mergers and Acquisitions
The linkage file reflects hospitals in the United States at the end of 2021.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
January 01, 2004 - Two-thirds of completed
claims against family practitioners in the United Kingdom were attributed to
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www.ahrq.gov/patient-safety/reports/liability/corbett.html
August 01, 2017 - patients, contribute to 7,000 deaths, and cost $21 billion in direct health care costs annually in the United … States. 19 Adverse drug events (ADEs) are multifactorial and are attributed to both human and system