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61. Debrief Example - Implementation Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-k.html
    May 01, 2017 - Where: Observed cases in the ambulatory surgery center (ASC). … Slide 5: Data Collection Baseline data collection period: 3/2/2015 – 3/6/2015 Number of cases … Case volume doesn’t allow sufficient time for a debrief between cases. … Smith’s cases Timeframe: Example: The week of 3/9/2015 – 3/13/2015 Slide 14 … Smith’s cases Timeframe:  Example: The week of 3/16/2015 – 3/20/2015 Slide

62. The Different Count Contributions to Retention (pdf file)
    psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
    January 01, 2024 - All RSI cases are not the same. … In 31 cases (67%) lap pads (18x18” cotton woven surgical sponges) were retained, in 11 cases (24%) “ … ) No Count Retention Cases and forty (87%) Correct Count Retention Cases. … or near miss cases. … factor in retained sponge cases.

63. Hospital-Acquired Diabetic Ketoacidosis. | PSNet
    psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
    October 28, 2020 - The Cases Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) with … hyperglycemia in the setting of type 1 diabetes is ineffective and can result in DKA, as these two cases … The remaining cases were caused by infection, steroid-induced hyperglycemia, acute stress from cardiac … In both the cases described above, a medical history with best possible medication history would have … In the two cases described above, reflexively testing beta-hydroxybutyrate may have triggered timelier

64. Improving Communication and Teamwork in the Surgical Environment
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-k-debrief.pptx
    June 01, 2015 - Framework 4 Data Collection Baseline data collection period: 3/2/2015 – 3/6/2015 Number of cases … Smith’s Cases 42065 42066 42067 42068 42069 0.5 0.75000000000000111 0.25 0.67000000000000115 0.5 … Smith’s cases Timeframe: Example: The week of 3/9/2015 – 3/13/2015   QI Study … Smith’s Cases 3/2/2015 3/3/2015 3/4/2015 3/5/2015 3/6/2015 3/9/2015 3/10/2015 3/11/2015 3/12/2015 3/ … Smith’s Cases 3/2/2015 3/3/2015 3/4/2015 3/5/2015 3/6/2015 3/9/2015 3/10/2015 3/11/2015 3/12/2015 3/

65. Final Progress Report: Utility of Predictive Systems in Diagnostic Errors (UPSIDE) (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/auerbach-report.pdf
    January 01, 2025 - We did this by carefully examining cases in medical centers connected to HOMERuN. … Reviewers then assessed cases in a randomized order, excluding patients whose cases were identified … on a minimum of 10 standard cases. … Only then did the teams proceed to adjudicate the study cases. … We addressed these concerns through training and inter-site over-read of cases.

66. Discrepant advanced directives and code status orders: a preventable medical error. | PSNet
    psnet.ahrq.gov/issue/discrepant-advanced-directives-and-code-status-orders-preventable-medical-error
    October 31, 2018 - Root cause analyses for these cases found that haste, inadequate communication, EMR discrepancies, knowledge … June 10, 2018 WebM&M Cases Poorly Advanced Directives … June 20, 2011 WebM&M Cases Medication Reconciliation … Pitfalls February 1, 2010 WebM&M Cases The … Wrongful Resuscitation April 1, 2008 WebM&M Cases

67. CHIPRA 212 Tables 5 to 8 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-212-tables-5-8.pdf
    June 02, 2025 - (7.5) * Data summarize characteristics of the broader population residing in ZIP codes of sampled cases … 16.2) * Data summarize characteristics of the broader population residing in ZIP codes of sampled cases … $78,691 * Data summarize characteristics of the broader population residing in ZIP codes of sampled cases … 100 * Data summarize characteristics of the broader population residing in ZIP codes of sampled cases

68. Outpatient insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United States, 2012-2017. | PSNet
    psnet.ahrq.gov/issue/outpatient-insulin-related-adverse-events-due-mix-errors-findings-two-national-surveillance
    March 10, 2021 - Most cases of medication mix-up involved rapid-acting insulin. … May 20, 2020 Key use cases for artificial intelligence to reduce the frequency of adverse … December 13, 2023 WebM&M Cases Missed Diagnosis of Addison … March 29, 2023 WebM&M Cases Hospital-Acquired Diabetic … November 4, 2020 WebM&M Cases Inpatient Stroke Management

69. Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative care. | PSNet
    psnet.ahrq.gov/issue/prevalence-triggers-and-patient-harm-identified-global-trigger-tool-specialized-palliative
    June 14, 2023 - Of the 26 cases identified by the GTT, 16 were considered part of the patient's disease trajectory or … Improving Diagnostic Safety and Quality April 26, 2023 WebM&M Cases … June 15, 2022 WebM&M Cases Engaging Seriously Ill Older … November 23, 2016 WebM&M Cases SNFs: Opening the Black … October 12, 2012 WebM&M Cases Poor Prognosis September

70. Autopsy interrogation of emergency medicine dispute cases: how often are clinical diagnoses incorrect? | PSNet
    psnet.ahrq.gov/issue/autopsy-interrogation-emergency-medicine-dispute-cases-how-often-are-clinical-diagnoses
    March 24, 2019 - Study Autopsy interrogation of emergency medicine dispute cases: how often are clinical … Autopsy interrogation of emergency medicine dispute cases: how often are clinical diagnoses incorrect … Autopsy interrogation of emergency medicine dispute cases: how often are clinical diagnoses incorrect … July 14, 2018 WebM&M Cases Shortcuts to Acetaminophen-induced … June 25, 2009 WebM&M Cases Delay in Initiating Antibiotics

71. The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
    March 27, 2008 - All of the Code 911 cases and 2 years of Code 912 cases were analyzed by at least one nurse and one … The most common wrong-side cases were herniorrhaphies (three cases). … Cases reported 2003 2004 2005 Code 911 9 21 22 Code 912 93a 104 98 a 2003 Code 912 cases were … Of the Code 912 cases analyzed, 68 (34 percent) were wrong-procedure cases, 51 (25 percent) were wrong … Complex cases had as many as 10 root causes.

72. Section 2, Technical Specifications (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-139-section-2.pdf
    January 01, 2014 - with TCD Select cases with TCD IPOT2008 _TCD Merge files, eliminate duplicate claims by … date of service for each ID IPOT2008_ Meas13Had 3 Select cases that had 3 or more claims … Cases with 3 or more health care encounters are retained, the rest are discarded. … The bdayCUT file will be merged in after denominator cases are correctly identified*/ /**IP**/ … who will be less than 2yrs old on Jan 1, 2005*/ OR EL_DOB < '19900101' /*deletes cases who

73. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/854383/psn-pdf
    January 01, 2024 - What can safety cases offer for patient safety? A multisite case study. … What can Safety Cases offer for patient safety? A multisite case study. … https://psnet.ahrq.gov/issue/what-can-safety-cases-offer-patient-safety-multisite-case-study “Safety … cases” are used in healthcare and other industries to communicate the safety of a product, system, … psnet.ahrq.gov/issue/using-safety-cases-industry-and-healthcare https://psnet.ahrq.gov/issue/safety-cases-digital-health-innovations-can-they-work

74. Validation of AHRQ’s Patient Safety Indicator for Accidental Puncture or Laceration (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Gallagher1.pdf
    January 01, 2004 - The proportion of cases confirmed as in-hospital APL events, the proportion of cases not confirmed … these cases were eliminated from the PSI. … 2 3.0 Serious cases 50 74.6 Not serious cases 10 14.9 Trauma 2 3.0 Trauma and PSI 1 1.5 Readmits … While our sample of trauma cases (three cases, 4.5 percent) is too small to draw definitive conclusions … ), readmissions (3 percent), and trauma cases (4.5 percent) leaves 88.5 percent of the cases identified

75. Masks-Surveillance-2-Appendix-Table-A-2 (xls file)
    effectivehealthcare.ahrq.gov/sites/default/files/masks-surveillance-2-appendix-table-a-2.xlsx
    March 01, 2020 - of COVID-19 in a house for 4 days before and for more than 24 hours after the primary cases developed … illness related to COVID-19 355 (124 households with index cases) Not reported for family contacts … Among index cases, 45% <18 years, 74% 18–59 years, 26% ≥60 years Not reported for family contacts Among … 212 (contacts of 45 cases) Median age 33 years 52% SARS-1 4.2% (9/212) ELISA-positive for SARS-CoV-1 … identified as of May 2003 Hong Kong Community Cases: SARS cases reported to Department of Health with

76. Masks-Appendix-Table-B-2-Surveillance-Report (xls file)
    effectivehealthcare.ahrq.gov/sites/default/files/Masks-appendix-table-b-2-surveillance-report.xlsx
    March 01, 2020 - of COVID-19 in a house for 4 days before and for more than 24 hours after the primary cases developed … illness related to COVID-19 355 (124 households with index cases) Not reported for family contacts … Among index cases, 45% <18 years, 74% 18–59 years, 26% ≥60 years Not reported for family contacts Among … 212 (contacts of 45 cases) Median age 33 years 52% SARS-1 4.2% (9/212) ELISA-positive for SARS-CoV-1 … identified as of May 2003 Hong Kong Community Cases: SARS cases reported to Department of Health with

77. A systems approach to morbidity and mortality conference. | PSNet
    psnet.ahrq.gov/issue/systems-approach-morbidity-and-mortality-conference
    July 22, 2020 - PSNet offers an online version of such conferences with presentation of cases and expert commentaries … July 22, 2020 Key use cases for artificial intelligence to reduce the frequency of adverse … May 4, 2022 View More Related Resources WebM&M Cases … January 26, 2022 A multidisciplinary model for reviewing severe maternal morbidity cases … Surgical M&M Conference: The M+M Matrix September 1, 2007 WebM&M Cases

78. Readmissions for Selected Infections Due to Medical Care: Expanding the Definition of a Patient Safety Indicator (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Gallagher2.pdf
    January 01, 2016 - The hospital-level estimate of cases of selected infection resulting from inpatient treatment (secondary … By attributing area-level PSI cases that occur because of inpatient care to the hospital-level PSI, … these cases were eliminated from the hospital-level PSI for this analysis. … The addition of 950 cases increases the hospital-level AHRQ PSI- based estimate of 3,858 cases of Selected … The area-level indicator identified 7,373 cases in New York State for 2001 (Table 1).

79. Calibrate Dx: A Resource to Improve Diagnostic Decisions (pdf file)
    www.ahrq.gov/sites/default/files/publications2/files/calibrate-dx-guide.pdf
    October 01, 2022 - SELECT CASES FOR REVIEW AND REFLECTION Choose three to five cases to review to assess your performance … If you need to narrow down a larger list of cases, opt for more recent cases as you may remember more … cases. … reviewing your cases at random. … What will you repeat in similar cases in the future?

80. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867232/psn-pdf
    January 01, 2025 - Role of remediation in cases of serious misconduct before UK healthcare regulators: a qualitative study … Role of remediation in cases of serious misconduct before UK healthcare regulators: a qualitative study … https://psnet.ahrq.gov/issue/role-remediation-cases-serious-misconduct-uk-healthcare-regulators- qualitative-study … study of regulators in the United Kingdom (UK) explored how remediation influences decision-making in cases … https://psnet.ahrq.gov/issue/role-remediation-cases-serious-misconduct-uk-healthcare-regulators-qualitative-study