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psnet.ahrq.gov/issue/national-surveillance-emergency-department-visits-outpatient-adverse-drug-events
February 27, 2009 - This study reports data from the National Electronic Injury Surveillance System, a representative sample … of 63 hospitals that provide data on emergency department (ED) visits for injuries, poisonings, and … Based on 2004-2005 data, the authors estimate that ADEs result in more than 700,000 ED visits yearly, … use. … April 19, 2011
Missed and delayed diagnoses in the emergency department: a study of closed
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psnet.ahrq.gov/web-mm/forgotten-drip
April 01, 2014 - The Case A 45-year-old man was brought to the emergency department by his friends because of a 1-day … A review of that day's laboratory data revealed that the patient had developed severe hypernatremia ( … Although no randomized data exist, many experts recommend placement of an ICP monitor in order to be … Use of neuromonitoring to objectively assess ICP in a patient whose clinical examination is poor remains … Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group.
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psnet.ahrq.gov/perspective/conversation-maureen-bisognano
February 26, 2025 - Improvement was not yet on the radar screen of health care in a major way. … I do believe that this way of using data is going to be a powerful driver for safety in the future. … We were looking at this NASA map, and we were saying that, in some ways, the use of electronic systems … Their research said that C + M = O. Context + Mechanism = Outcome. … in every context reliably to produce a certain outcome.
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psnet.ahrq.gov/issue/arrival-ambulance-explains-variation-mortality-time-admission-retrospective-study-admissions
January 29, 2018 - Previous research has shown that patients admitted to the hospital on the weekend are at increased risk … hospital during the day on Sunday. … Investigators suggest that prior research supporting the weekend effect is overly reliant on administrative … admitted on the weekend). … use, patient outcomes, and costs.
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psnet.ahrq.gov/issue/citation-classics-patient-safety-research-invitation-contribute-online-bibliography
January 19, 2011 - Same Author(s)
Tracing the foundations of a conceptual framework for a patient safety … March 5, 2025
An epistemology of patient safety research: a framework for study design … June 13, 2018
Biases in detection of apparent "weekend effect" on outcome with administrative … coding data: population based study of stroke. … November 25, 2015
'Sorry, I meant the patient's left side': impact of distraction on
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psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
July 10, 2024 - His research interests include comparative effectiveness; the use of outcomes data to improve the quality … The first track was that we did a fairly comprehensive review of the health services research literature … represent an adverse outcome of inpatient care. … Do you feel that that's a reasonable use of PSIs? … If people use the data to pose questions, I think that's great.
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psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
October 30, 2024 - Other organizations employ variations on this model, although the use of a board-certified addiction … Outpatient services were focused on reducing opioid prescribing, but not on the use of MAT for the treatment … A downstream impact is the ability to cohort patients for purposes of clinical outcome tracking on objectives … Treatment of substance use disorders is a relatively new field and a new specialty. … Department of Health and Human Services, the Agency for Healthcare Research and Quality, or of the submitter
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - strategies for torsades de pointes The Case A 54-year-old man with a history of tobacco use presented … The patient thought the pain was related to his diet and put himself on a juice cleanse one week before … degenerated into VF. 1 The case exemplifies how a poor patient outcome is often the product of a series … Impact of clinical decision support preventing the use of QT-prolonging medications for patients at risk … a Severely Negative Outcome
September 29, 2021
WebM&M Cases
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psnet.ahrq.gov/issue/guide-patient-and-family-engagement-environmental-scan-report
August 01, 2012 - May 7, 2014
Findings and Lessons From the Improving Quality Through Clinician Use of … May 1, 2017
Improving the Measurement of Surgical Site Infection Risk Stratification/ … Outcome Detection: Final Contract Report. … for Users of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture. … November 21, 2016
Eliminating CAUTI: Interim Data Report: A National Patient Safety Imperative
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psnet.ahrq.gov/node/836876/psn-pdf
May 16, 2022 - EMS clinical data based on a national EMS data standard,
the National EMS Information System, or NEMSIS … and harm.2 The research team found that,
compared with a random sampling strategy, the EMSTT was more … on individual error to
a Just Culture where the system is the primary focus. … been adapted for use in the prehospital setting.3 Safety culture surveys can be
used for a variety … rich electronic patient data that are
becoming increasingly standardized and linked with hospital outcome
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psnet.ahrq.gov/perspective/update-safety-culture
January 22, 2020 - disparate ("the doctors think it's fine, and no one else does"), and we can link the data to specific … Psychological safety has a huge impact on how teams perform and the care experience.( 9 ) The ability … Consistent use of these tools is a great way to embed the desired behaviors and improve safety culture … Focusing on a few specific insights of safety culture at the clinical unit level is a valuable endeavor … outcome in a high-volume thoracic surgery operating room team.
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psnet.ahrq.gov/issue/adverse-events-and-near-miss-reporting-nhs
August 30, 2023 - This study evaluated the utility of a voluntary reporting system from several National Health Service … the low rate of incidents associated with a catastrophic outcome. … The authors conclude that this type of reporting system can provide useful information on a national … June 5, 2013
A simulation design for research evaluating safety innovations in anaesthesia … March 12, 2025
Strengthening the use of artificial intelligence within healthcare delivery
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psnet.ahrq.gov/node/836885/psn-pdf
May 16, 2022 - Use of a treadmill may be safer than having the patient walk up three flights of steps, as
stairwells … , and conducting research on in-hospital resuscitation.15,16 On January 1, 2000, the
American Heart … The use of mock codes can help providers in clinical settings gain hands-on experience with
resuscitative … outcome after out-of-hospital cardiorespiratory
arrest: a randomized clinical trial. … Recommended guidelines for reviewing, reporting,
and conducting research on in-hospital resuscitation
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psnet.ahrq.gov/node/846564/psn-pdf
March 29, 2023 - and
uptake of the guides.6
During 2022, research into technological approaches was a major theme of … Clinical Decision Support
The most prominent focus in the 2022 research on technology, based on the … Usability of CDS systems was a large focus of research in 2022. … actual use of the
tool was low. … on color scales, location, and types of data displayed.
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psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - Review the evidence on the effectiveness of quality improvement efforts to reduce inappropriate
antibiotic … The use of broad-spectrum antibiotics rose significantly
during the 1990s. … tragic outcome likely related to inappropriate prescribing of antibiotics. … While the
complications and ultimate outcome of this case are exceedingly rare, unfortunately, the problem … marked increase in prescribing of broad-spectrum antibiotics, the use of which doubled
during the 1990s
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psnet.ahrq.gov/node/33785/psn-pdf
May 01, 2015 - We'd spent a long time thinking about
components of perioperative care—the use of antibiotics, the use … For example, does it matter if that anastomosis is hand-sewn, or is the use of
a stapler safer? … No matter how we measured skill on the front
end or which outcome or aspect of quality we evaluated … big data approaches to assessing spatial movements of instruments that appear on a screen
and ultimately … But particularly for procedures or specialties where surgeons
don't do a million of them, so the outcome
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psnet.ahrq.gov/node/33707/psn-pdf
February 01, 2011 - development, history of quality management, health services research, data management, quality tools … At UT Houston, the CS&E course can also be taken for credit by students who are
working on a Masters … A less quantitative, but extremely important
outcome is that the course often gives frustrated and demoralized … guideline/protocol
development and
implementation
3. outcome measurement
4. health services research … and
Development meeting)
2. 2 hr video conferences
every 2 weeks of didactic
sessions, presentations
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psnet.ahrq.gov/web-mm/novel-drug-misuse
September 30, 2010 - by the Data Safety and Monitoring Board on the basis of clear lack of effect. … FDA-approved labeling indications help to guide clinicians in the use of a new therapeutic agent. … the impact on clinical outcomes. … Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs … Example of a two-page order form explicitly stating patient selection criteria for the use of drotrecogin
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psnet.ahrq.gov/node/49533/psn-pdf
March 01, 2007 - for error, they likely had little bearing on the
outcome of this particular case, although the issue … likely had little impact on the unfortunate
outcome—particularly in comparison with the failure to initiate … a change in antibiotics, and such a change may have favorably
affected the outcome. … data chronologically based upon the time of the sample, not at the time when the lab
test was performed … of the pathogen and final susceptibility results might be the use of newer rapid
susceptibility tests
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psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
June 28, 2023 - The primary outcome evaluated was physician documentation of any adverse effects resulting from the newly … Date First Implemented
2015
Problem Addressed
Previous research on … Clinics in the control group provided patient data for chart review to study outcome data, but no patients … Patients were called between 9 a.m. and 7 p.m. on a rotating schedule based on the availability of the … Department of Health and Human Services, the Agency for Healthcare Research and Quality, or of the submitter