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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43763/psn-pdf
    April 22, 2015 - The nurse's role in medication safety. April 22, 2015 Durham B. The nurse's role in medication safety. Nursing (Brux). 2015;45(4). doi:10.1097/01.NURSE.0000461850.24153.8b. https://psnet.ahrq.gov/issue/nurses-role-medication-safety-0 Nurses perform a critical role in preventing medication errors. This commentary e…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60163/psn-pdf
    March 25, 2020 - Broken, fragmented health-care system failed daughter who died by suicide. March 25, 2020 Klowak M. CBC News. March 9, 2020. https://psnet.ahrq.gov/issue/broken-fragmented-health-care-system-failed-daughter-who-died-suicide System weaknesses are often at the root of never events. This news story discusses the suic…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34799/psn-pdf
    December 23, 2008 - Drug related admissions to a cardiology department; frequency and avoidability. December 23, 2008 Hallas J, Haghfelt T, Gram LF, et al. Drug related admissions to a cardiology department; frequency and avoidability. J Intern Med. 1990;228(4):379-84. https://psnet.ahrq.gov/issue/drug-related-admissions-cardiology-d…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46804/psn-pdf
    January 01, 2021 - Retained guidewires in the Veterans Health Administration: getting to the root of the problem. May 9, 2018 Cherara L, Sculli GL, Paull DE, et al. Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem. J Patient Saf. 2021;17(8):e991-e928. doi:10.1097/PTS.0000000000000475. htt…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44879/psn-pdf
    February 10, 2016 - Soaring numbers of 111 callers forced to wait for a call back. February 10, 2016 Donnelly L. The Telegraph. January 31, 2016. https://psnet.ahrq.gov/issue/soaring-numbers-111-callers-forced-wait-call-back Delays in care and diagnosis can result in patient harm. This news article reports on the trend of delays in …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41778/psn-pdf
    January 18, 2013 - An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery. January 18, 2013 Symons NRA, Almoudaris AM, Nagpal K, et al. An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46677/psn-pdf
    June 25, 2018 - Diagnostic errors in paediatric cardiac intensive care. June 25, 2018 Bhat PN, Costello JM, Aiyagari R, et al. Diagnostic errors in paediatric cardiac intensive care. Cardiol Young. 2018;28(5):675-682. doi:10.1017/S1047951117002906. https://psnet.ahrq.gov/issue/diagnostic-errors-paediatric-cardiac-intensive-care R…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847735/psn-pdf
    May 30, 2023 - SOPS Ambulatory Surgery Center Survey: What You Need to Know. May 30, 2023 Agency for Healthcare Policy and Research: April 27, 2023. https://psnet.ahrq.gov/issue/sops-ambulatory-surgery-center-survey-what-you-need-know Ambulatory surgery centers (ASC) experience a variety of error types that can be exacerbated by…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848829/psn-pdf
    May 10, 2023 - Lessons from the Covid War: An Investigative Report. May 10, 2023 Covid Crisis Group. New York: Public Affairs; 2023. ISBN?: ?9781541703803. https://psnet.ahrq.gov/issue/lessons-covid-war-investigative-report The transfer of failure experiences to generate learning and improve service is a complicated responsibilit…

  10. Tool 3 Continued | Agency for Healthcare Research and Quality

    www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/ahcp-sample.html
    March 01, 2025 - Re-Engineered Discharge (RED) Toolkit Tool 3 Continued Previous Page Next Page Table of Contents Re-Engineered Discharge (RED) Toolkit Tool 1: Overview Tool 2: How To Begin the Re-engineered Discharge Implementation at Your Hospital How CMS Measures the "30-Day All Cause Rehospitalization Rate…

  11. 2009Maseddissuedescriptionreviewed (pdf file)

    hcup-us.ahrq.gov/db/state/sedddist/2009MASEDDissuedescriptionReviewed.pdf
    January 01, 2009 - The HCUP Central Distributor State Emergency Department Databases (SEDD) for Massachusetts 2009 contains problems with the recode of payer information into PAY1 and PAY2 in the 4th quarter data. Incorrect values of PAY1 and PAY2 were assigned to 122,919 discharges (4.8% of all discharges in the year). In the majori…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73238/psn-pdf
    May 12, 2021 - Medical Residents and Burnout May 12, 2021 Coverdale J, West CP, Roberts LW, eds. Acad Med. 2021;96(5):611-769;e14-e21. https://psnet.ahrq.gov/issue/medical-residents-and-burnout Medical training is a demanding experience that impacts a learner’s ability to provide safe care, cope, and remain healthy. This is…

  13. Tool 3 Continued | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/ahcp-sample.html
    March 01, 2025 - Re-Engineered Discharge (RED) Toolkit Tool 3 Continued Previous Page Next Page Table of Contents Re-Engineered Discharge (RED) Toolkit Tool 1: Overview Tool 2: How To Begin the Re-engineered Discharge Implementation at Your Hospital How CMS Measures the "30-Day All Cause Rehospitalization Rate…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73103/psn-pdf
    March 31, 2021 - About 90% of anorectal abscesses are caused by non-specific obstruction and subsequent infection of

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842919/psn-pdf
    February 01, 2023 - The remaining cases were caused by infection, steroid-induced hyperglycemia, acute stress from cardiac

  16. Maternal and Child Health Care: Effectiveness Measures | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/nhqrdr/chartbooks/healthyliving/mcheff-measures.html
    June 01, 2018 - Meningococcal diseases are infections caused by the bacteria Neisseria meningitidis. 12 Neisseria

  17. Archived: Skin Cancer: Counseling, 2003 | United States Preventive Services Taskforce

    www.uspreventiveservicestaskforce.org/uspstf/recommendation/skin-cancer-counseling-2003
    October 06, 2003 - bed exposure, 4 found a positive association, particularly if the dose of exposure was high and if it caused

  18. Archived: Iron Deficiency Anemia in Pregnant Women and Young Children: Screening and Supplementation, 1996 | United States Preventive Services Taskforce

    www.uspreventiveservicestaskforce.org/uspstf/recommendation/iron-deficiency-anemia-pregnant-women-young-children-screening-supplementation-1996
    January 01, 1996 - Treatment of some forms of anemia not caused by iron deficiency (e.g., vitamin B 12 or folate deficiency

  19. The CAHPS Ambulatory Care Improvement Guide: Determining Where to Focus Efforts to Improve Patient Experience (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/5-determining-focus/cahps-ambulatory-care-guide-section-5.pdf
    May 01, 2017 - o What caused complaints today? o What cost too much? o What was wasted?

  20. Management of Colonic Diverticulitis | Effective Health Care (EHC) Program

    effectivehealthcare.ahrq.gov/products/diverticulitis/protocol
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