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9521. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33605/psn-pdf
      March 12, 2021 - Medication Administration Errors March 12, 2021 MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. 2021. https://psnet.ahrq.gov/primer/medication-administration-errors Updated in March 2021. Originally published in January 2018 by researchers at the University of California, San Fra…

9522. Patient Identification Errors: A Systems Challenge | PSNet
      psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
      February 23, 2011 - Patient Identification Errors: A Systems Challenge Citation Text: Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Googl…

9523. Environmental Safety in the OR | PSNet
      psnet.ahrq.gov/web-mm/environmental-safety-or
      May 19, 2015 - Environmental Safety in the OR Citation Text: Linkin DR, Lautenbach E. Environmental Safety in the OR . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

9524. Reconciling Doses | PSNet
      psnet.ahrq.gov/web-mm/reconciling-doses
      August 14, 2017 - SPOTLIGHT CASE Reconciling Doses Citation Text: Federico F. Reconciling Doses. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

9525. Ch 9-User-Guide-To-Ocer 130129 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/ch_9-user-guide-to-ocer_130129.pdf
      September 21, 2012 - 129 Abstract The feasibility of a study often rests on whether the projected number of accrued patients is adequate to address the scientific aims of the study. Accordingly, a rationale for the planned study size should be provided in observational comparative effectiveness research (CER) study protocols. This chap…

9526. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49545/psn-pdf
      September 01, 2007 - Coming Undone: Failure of Closure Device September 1, 2007 Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device The Case A 65-year-old man underwent coronary angiography because of atypical exertional chest…

9527. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33788/psn-pdf
      June 01, 2015 - In Conversation With… Christine Cassel, MD June 1, 2015 In Conversation With… Christine Cassel, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-christine-cassel-md Editor's note: Christine Cassel, MD, is President and CEO of the National Quality Forum (NQF). Dr. Cassel, one of the foun…

9528. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49787/psn-pdf
      March 01, 2017 - Diagnosing a Missed Diagnosis March 1, 2017 Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis The Case A 57-year old woman was admitted to the hospital with cough, slurred speech, confusion, and disorientation. She was taking mod…

9529. Chapter 5 | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter5.html
      August 01, 2022 - Designing Consumer Reporting Systems for Patient Safety Events Chapter 5 Previous Page Next Page Table of Contents Designing Consumer Reporting Systems for Patient Safety Events Executive Summary Chapter 1. Background Chapter 2. Conceptual Framework and Design Chapter 3. Description of Metho…

9530. Learn-From-Defects-Facilitator-Guide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
      May 01, 2017 - AHRQ Safety Program for Perinatal Care Sensemaking and Learn From Defects for Perinatal Safety Sensemaking and Learn From Defects for Perinatal Safety SAY: The Sensemaking and Learn From Defects module of the Safety Program for Perinatal Care will help you identify recurring defects in your system and apply Comprehen…

9531. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
      July 01, 2023 - Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide AHRQ Safety Program for Perinatal Care Slide 1: Sensemaking and Learn From Defects for Perinatal Safety Say: The Sensemaking and Learn From Defects module of the Safety Program for Perinatal Care will help you identify recurring …

9532. Chapter 4. Assessing Surgeon Acceptance of Risk Adjustment Models | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ssi/ssi4.html
      April 01, 2018 - Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection Chapter 4. Assessing Surgeon Acceptance of Risk Adjustment Models Previous Page Next Page Table of Contents Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection Executiv…

9533. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60376/psn-pdf
      July 30, 2020 - COVID-19: Team and Human Factors to Improve Safety July 30, 2020 Zipperer L. COVID-19: Team and Human Factors to Improve Safety. PSNet [internet]. 2020. https://psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety Background The rapid transmission of COVID-19 has resulted in an international pandem…

9534. Decision Making and Clinical Work of Test Result Followup in Health Information Technology Settings | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/decision-making-and-clinical-work-test-result-followup-health-information
      January 01, 2023 - Decision Making and Clinical Work of Test Result Followup in Health Information Technology Settings Project Final Report ( PDF , 364.79 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and d…

9535. Strategy 6P: Service Recovery Programs | Agency for Healthcare Research and Quality
      www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/customer-service/strategy6p-service-recovery.html
      April 01, 2022 - Strategy 6P: Service Recovery Programs Contents 6.P.1. The Problem 6.P.2. The Intervention 6.P.3. Implementing This Intervention 6.P.4. The Impact of Service Recovery Programs References    Download Strategy 6P:   Service Recovery Programs  (PDF, 748 KB)     6.P.1. The Problem No ma…

9536. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare, August 1, 2025 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/dx-safety-workgroup-meeting-notes-aug2025.pdf
      September 01, 2025 - Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare, August 1, 2025 Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare August 1, 2025, 10 AM–noon 1 Workgroup Goal: Established by Senate Report 115-150. The Senate Committee on Appropriation…

9537. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare July Meeting Summary (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/IAWG-July-2024-meeting-notes.pdf
      January 01, 2024 - Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare July Meeting Summary Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare July Meeting Summary Workgroup Goal: Established by Senate Report 115-150. The Senate Committee on Appropriations requ…

9538. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40785/psn-pdf
      May 04, 2012 - A framework for evaluating the appropriateness of clinical decision support alerts and responses. May 4, 2012 McCoy AB, Waitman LR, Lewis JB, et al. A framework for evaluating the appropriateness of clinical decision support alerts and responses. J Am Med Inform Assoc. 2012;19(3):346-52. doi:10.1136/amiajnl- 2011-…

9539. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44579/psn-pdf
      September 01, 2016 - Increased appropriateness of customized alert acknowledgement reasons for overridden medication alerts in a computerized provider order entry system. September 1, 2016 Dekarske BM, Zimmerman CR, Chang R, et al. Increased appropriateness of customized alert acknowledgement reasons for overridden medication alerts i…

9540. Cap 2 Firstpass
      cds.ahrq.gov/sites/default/files/cds/artifact/396/cap_2_FirstPass%20.html
      November 01, 2016 - Conditional: For patients with CURB-65 scores ≥2, more-intensive treatment that is, hospitalization or, where appropriate … CURB-65 scores ≥2     Action: more-intensive treatment that is, hospitalization     Action: where appropriate … If patients with CURB-65 scores ≥2 Then more-intensive treatment that is, hospitalization OR where appropriate