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2481. Exhibit 9. Top five minimal cut sets for the basic case | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/stpra/stpraexh9.html
      April 01, 2018 - Model Probability Estimates References Cut Set Contributed Probability Events

2482. Final Progress Report: Improving quality of postoperative pain care through innovative use of electronic health records (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/hernandez-boussard-report.pdf
      January 01, 2024 - postoperative pain is common and too often poorly managed, which may cause severe functional impairment, adverse … events, impaired care of the underlying diseases, transition to chronic pain, and decreased quality … and multivariate modeling were used to estimate associations between inpatient gabapentin use and adverse

2483. CHIPRA 119 Section 5, Literature Review and Discussion (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-119-section-5-lit-review.pdf
      March 19, 2012 - These risk factors put infants at risk for hypothermia and are associated with adverse outcomes. … This chain of events contributes to peripheral vasoconstriction, pulmonary vasoconstriction deterioration … The study concluded that hypothermia is associated with adverse outcomes. … newborns with cold injury or hypothermia, or during hypoxia could lead to malnourishment, and fatal events … Resuscitative efforts also improved chance of hypothermic events.

2484. AHRQ Surveys on Patient Safety CultureTM (SOPS®) Hospital Survey Version 2.0 with HIT, V&E, and Workplace Safety Supplemental Items for the SOPS Hospital Survey Survey Data File Specifications (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/HSOPS_2-0_HIT_WP_VE%20%20Data_Specs-2021.pdf
      January 01, 2021 - 5 = Always 9 = Does Not Apply or Don’t Know blank = MISSING SECTION D: Reporting Patient Safety Events … In the past 12 months, how many patient safety events have you reported? … Hospital management seems interested in patient safety only after an adverse event happens F3 Column … Supervisor, Manager, or Clinical Leader SECTION C: Communication SECTION D: Reporting Patient Safety Events

2485. AHRQ Surveys on Patient Safety CultureTM (SOPS®) Hospital Survey Version 2.0 with HIT, V&E, and Workplace Safety Supplemental Items for the SOPS Hospital Survey Survey Data File Specifications (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/HSOPS-2-0-Survey-HIT-WP-VE-Data-File-Spec.pdf
      March 24, 2022 - 5 = Always 9 = Does Not Apply or Don’t Know blank = MISSING SECTION D: Reporting Patient Safety Events … In the past 12 months, how many patient safety events have you reported? … Hospital management seems interested in patient safety only after an adverse event happens F3 Column … Supervisor, Manager, or Clinical Leader SECTION C: Communication SECTION D: Reporting Patient Safety Events

2486. TeamSTEPPS 2.0 Module 1: Introduction
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule1.pptx
      January 01, 2011 - Washington state, improved the time from decision to the performance of a Caesarean section, with no adverse … Video Discussion Think about the breakdowns you observed in the stories: Can you think of similar events … Of course, you would want to scrub them so that you're only sharing the sequence of events.

2487. Anticipatory Guidance Regarding Hydroxyurea Treatment for Children With Sickle Cell Anemia (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-213-fullreport.pdf
      January 01, 2019 - Hydroxyurea is indicated for pediatric patients with SCA who have recurrent vaso‐occlusive events, including … even more pronounced in older children with SCA, as they are hospitalized more often for the pain events … • Hydroxyurea works in all age groups to prevent acute events and chronic organ dysfunction. … complications have been associated thus far with hydroxyurea use in children, though research about adverse … Impact of hydroxyurea on clinical events in the BABY HUG trial. Blood 2012; 120(22):4304‐10.

2488. Mutual Support: Severe Hypertension (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support-speaker-notes.pdf
      July 01, 2023 - I would like to discuss some of the events surrounding Ms. Smith’s delivery yesterday. … I would like to discuss some of the events surrounding Ms. Smith’s delivery yesterday. … lead to stroke or seizures she needs to know what treatment options are available to prevent such adverse

2489. Mutual Support: Severe Hypertension - PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support.pptx
      July 01, 2023 - I would like to discuss some of the events surrounding Ms. Smith’s delivery yesterday. … I would like to discuss some of the events surrounding Ms. Smith’s delivery yesterday. … can lead to stroke or seizures she needs to know what treatment options are available to prevent such adverse

2490. Final Progress Report: What Is Patient Safety in the Medical Home? (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/dy-report.pdf
      January 01, 2024 - diagnoses; • Delay in proper treatment or preventive services; • Medication errors and preventable adverse … drug events; 3 R01HS024859 What is Patient Safety in the Medical Home? … Primary care workers anticipated safety events by thinking about the information they may be missing … that primary care workers used omissions as a cognitive representation to anticipate unwanted safety events … Agency for Healthcare Research and Quality, Rockville, MD http://archive.ahrq.gov/news/events/other

2491. Urine Culture Practices in the ICU; Antibiotic Stewardship; Practical ICU Tools; Using Results from the Safety Culture Surveys | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/urine-culture-practices-icu-slides.html
      December 01, 2017 - Urine Culture Practices in the ICU; Antibiotic Stewardship; Practical ICU Tools; Using Results from the Safety Culture Surveys Slide 1 Urine Culture Practices in the ICU; Antibiotic Stewardship; Practical ICU Tools; Using Results from the Safety Culture Surveys Mohamad Fakih, MD, MPH Medical Director, Infect…

2492. Hybrid Cardiac Rehabilitationi (HYCR) Tools and Resources Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/hycr-tools-resources-guide.pdf
      April 28, 2023 - ......................................................................................... 84 4a: Adverse … Events and Emergency Protocol ...................................................................... … The contributor for each resource is included. 4a: Adverse Events and Emergency Protocol Contributor … • Implement record of critical and non-critical events and complications on site vs HYCR • Although

2493. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=206
      January 01, 2024 - This article considers how health literacy plays a part in events that lead up to children's hospitalizations … Keywords: Adverse Events, Catheter-Associated Urinary Tract Infection (CAUTI), Community-Acquired Infections

2494. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=219
      January 01, 2024 - Keywords: Adverse Events, Education: Continuing Medical Education, Medical Errors, Patient Safety, Provider … Laboratory test results were delayed an average of 62% during downtime events.

2495. 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive in a Single Hospital? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Meliones_40.pdf
      January 01, 2006 - Six Sigma initiatives in these areas have resulted in a 44 percent reduction in adverse drug events,

2496. Diagnostic Safety Issue Brief 21 Diagnostic Stewardship as a Model To Improve the Quality and Safety of Diagnosis (pdf file)
      www.ahrq.gov/sites/default/files/publications2/files/dx-safety-21-diagnostic-stewardship.pdf
      August 01, 2024 - However, it is difficult to infer changes in safety or adverse outcomes based on test use or even inappropriate … consider the total value of diagnostic stewardship, including downstream effects on length of stay, adverse … events, clinician satisfaction, and patient experience. … Common contributing factors of diagnostic error: a retrospective analysis of 109 serious adverse event … Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events.

2497. Ratio of Magnetic Resonance Imaging Scans to Computed Tomography Scans for the Evaluation of Children with Atraumatic Headache (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-196-fullreport.pdf
      January 01, 2020 - EHRs may be limited by interoperability with other providers’ EHRs that may likewise capture imaging events … Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the … Sedation and general anesthesia in children undergoing MRI and CT: Adverse events and outcomes.

2498. Making Healthcare Safer Practices: 10. Harms Due to Opioids (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/opioids-1.pdf
      March 01, 2020 - National Action Plan for Adverse Drug Event Prevention.Washington, DC: U.S. … events, and patient-reported outcomes. … Of 103 patients in this observational study, no cases of severe precipitated withdrawal or adverse events … No serious adverse events related to treatment occurred. … No cases of severe precipitated withdrawal and no serious adverse events were observed.

2499. Using Rapid-Cycle Research to Reach Goals: Awareness, Assessment, Adaptation, Acceleration (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/final-rapid-cycle-research-guidance.pdf
      June 01, 2015 - http://pbrn.ahrq.gov/events/advanced-methods-primary-care-research-stepped-wedge-design AHRQ PBRN … View the Webinar recording on AHRQ’s PBRN Events page here: https://pbrn.ahrq.gov/events/dissemination … http://pbrn.ahrq.gov/events/advanced-methods- primary-care-research-stepped-wedge-design. … information systems can reduce medical errors and might pose a viable option for the prevention of adverse … drug events.

2500. Nutritional Research Series: Volume 5: Comparison of Translational Patterns in Two Nutrient–Disease Associations (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/nutrtp5.pdf
      October 01, 2011 - The trials were expensive to conduct, and in some cases, they identified adverse effects of nutrient … Figure 1 describes alternative scenarios for the possible cascade of translational events. … Vitamin E supplementation and cardiovascular events in high-risk patients. … Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS) … For randomized trials, we extracted number of events in the intervention and control groups.