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digital.ahrq.gov/sites/default/files/docs/citation/evaluation-stage-3-meaningful-use-pa-ut-final-report.pdf
February 01, 2015 - partners with sufficient capacity to use electronic information is arguably
the single most important barrier
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/research/reaching-adolescents-full.pdf
April 01, 2024 - Person-Centered Preventive Healthcare: Reaching Adolescents to Deliver Preventive Services
Person-Centered Preventive Healthcare:
Reaching Adolescents to Deliver Preventive Services
Prepared for
Agency for Healthcare Research and Quality
Center for Evidence and Practice Improvement
Prepared by
RTI I…
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/alarm-fatigue-1.pdf
March 01, 2020 - Making Healthcare Safer Practices: 13. Alarm Fatigue
Alarm Fatigue 13-1
13. Alarm Fatigue
Authors: Meghan Woo, Sc.D., and Olivia Bacon
Reviewer: Ann Gaffey, R.N., M.S.N., CPHRM, DFASHRM
Introduction
Alarm fatigue occurs when clinicians experience high exposure to medical device alarms, causing alarm
desensitiz…
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psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary …
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psnet.ahrq.gov/web-mm/poorly-advanced-directives
August 01, 2018 - Poorly Advanced Directives
Citation Text:
Anderson WG. Poorly Advanced Directives. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
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psnet.ahrq.gov/web-mm/dressed-failure
September 01, 2011 - DRESSed for Failure
Citation Text:
Abramson EL, Kaushal R. DRESSed for Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
February 21, 2020 - Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.
Citation Text:
Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
…
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psnet.ahrq.gov/node/72834/psn-pdf
March 10, 2021 - Approach to Improving Patient Safety: Communication
March 10, 2021
Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet
[internet]. 2021.
https://psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
Introduction
Each one of the countless necessa…
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psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
January 07, 2015 - Haste Makes Care Unsafe
Citation Text:
Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…
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digital.ahrq.gov/sites/default/files/docs/survey/qualitative-interview-ehr-implementation.pdf
June 16, 2021 - Qualitative Interview Questions for Electronic Health Record Implementation
Qualitative Interview Questions for Electronic Health Record Implementation
Michigan Public Health Institute, Ann Arbor MI
This is an interview guide designed to be conducted with administrators, clinical staff,
implementers, and office st…
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www.ahrq.gov/chsp/events/coe-workshopissuebrief.html
January 01, 2017 - A Summary of the First Annual Workshop of AHRQ’s Comparative Health System Performance Initiative
Issue Brief
The Agency for Healthcare Research and Quality and the Coordinating Center of the Comparative Health System Performance Initiative held a workshop September 29, 2016, to share learning a…
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psnet.ahrq.gov/node/49848/psn-pdf
January 01, 2019 - Inadequate Preanesthetic Evaluation, Airway Trouble
November 1, 2018
Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
The Case
Case #1:
A 34-year-old woman was scheduled for a hysteroscopy under g…
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psnet.ahrq.gov/node/50769/psn-pdf
February 15, 2017 - Cultural Competence and Patient Safety
December 27, 2019
Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
Background
Culture can be defined as the “personal identification, language, thoughts, co…
-
www.ahrq.gov/sites/default/files/publications/files/coe-workshopissuebrief.pdf
January 11, 2017 - A Summary of the First Annual Workshop of AHRQ’s Comparative Health System Performance Initiative
A Summary of the First Annual
Workshop of AHRQ’s
Comparative Health System
Performance Initiative
Based on the workshop
discussions, a number of important
takeaways will inform future work
of the initiative:
•…
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psnet.ahrq.gov/node/60952/psn-pdf
September 30, 2020 - When the Lytes Go Out: A Case of Inpatient Cardiac
Arrest
September 30, 2020
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
Disclosure of Relevant Financial Relationships: As a pr…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module2/putoolkit_module2_tools.docx
February 16, 2011 - Pressure Ulcer Prevention Toolkit
Pressure Ulcer Prevention Toolkit
Module 2 Tools
2A: Multidisciplinary Team
2B: Quality Improvement Process
2C: Current Process Analysis
2D: Assessing Pressure Ulcer Policies
2E: Assessing Screening for Pressure Ulcer Risk
2F: Assessing Pressure Ulcer Care Planning
2I: Action Plan
…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Preventing Pressure Injuries in Hospitals
Preventing Pressure Injuries in Hospitals
ADD Name of Hospital Here
Module 1 – Understanding Why Change Is Needed
1
Ice Breaker
Describe an interesting fact about yourself.
2
Compelling Reasons To Implement Program
Pressure injury rates continue to escalate.
The inci…
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psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
January 31, 2011 - Lost in Sign Out and Documentation
Citation Text:
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/bundlingcps.pdf
March 01, 2014 - Bundling Clinical Preventive Services: A Review of Definitions and Concepts from the Literature
Bundling Clinical Preventive Services:
A Review of Definitions and Concepts
from the Literature
Prepared for:
Agency for Healthcare Research and Quality
U.S. Departme…
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psnet.ahrq.gov/node/49594/psn-pdf
December 01, 2009 - Standard Deviations
December 1, 2009
Sabin JE. Standard Deviations. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/standard-deviations
Case Objectives
Understand the safety risks associated with patients being discharged against medical advice
(AMA).
Recognize safety risks associated with being part of a …