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Showing results for "caused".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73388/psn-pdf
    June 16, 2021 - Reducing surgical specimen errors through multidisciplinary quality improvement. June 16, 2021 Holstine JB, Samora JB. Reducing surgical specimen errors through multidisciplinary quality improvement. Jt Comm J Qual Patient Saf. 2021;47(9):563-571. doi:10.1016/j.jcjq.2021.04.003. https://psnet.ahrq.gov/issue/reduci…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45343/psn-pdf
    August 10, 2016 - Medication errors involving the intravenous administration route: characteristics of voluntarily reported medication errors. August 10, 2016 Wolf ZR. Medication Errors Involving the Intravenous Administration Route: Characteristics of Voluntarily Reported Medication Errors. J Infus Nurs. 2016;39(4):235-48. doi:10.…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37859/psn-pdf
    June 25, 2008 - What can we learn about patient safety from information sources within an acute hospital: a step on the ladder of integrated risk management? June 25, 2008 Hogan H, Olsen S, Scobie S, et al. What can we learn about patient safety from information sources within an acute hospital: a step on the ladder of integrated…

  4. Remember T.E.A.M.S. to Improve Safety Culture (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/improve/teams-infographic.pdf
    March 01, 2017 - Remember T.E.A.M.S. to Improve Safety Culture T E A M S Team Formation Excellent Communication Assess What’s Working Meet Monthly Sustain Efforts The most effective teams are diverse. Make sure your team includes people of differing perspectives and roles. Communication should be effective. Commu…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60559/psn-pdf
    June 03, 2020 - Omissions of care in nursing home settings: a narrative review. June 3, 2020 Ogletree AM, Mangrum R, Harris Y, et al. Omissions of care in nursing home settings: a narrative review. J Am Med Dir Assoc. 2020;21(5):604-614.e6. doi:10.1016/j.jamda.2020.02.016. https://psnet.ahrq.gov/issue/omissions-care-nursing-home-…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841770/psn-pdf
    December 21, 2022 - A recent two-fold increase in medical adverse event deaths among US inpatients. December 21, 2022 Oura P, Sajantila A. A recent two-fold increase in medical adverse event deaths among US inpatients. J Public Health Res. 2022;11(4):227990362211399. doi:10.1177/22799036221139935. https://psnet.ahrq.gov/issue/recent-…

  7. What is the NPSD’s Role in Quality and Patient Safety? | Agency for Healthcare Research and Quality

    www.ahrq.gov/npsd/quality-patient-safety/index.html
    August 01, 2020 - What is the NPSD’s Role in Quality and Patient Safety? By enabling providers, PSOs, and, eventually others to contribute nonidentifiable patient safety data to the NPSD, the stage has been set for breakthroughs in our understanding of how best to improve patient safety. The NPSD will facilitate the aggregation …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34700/psn-pdf
    January 04, 2017 - Reducing adverse drug events: lessons from a breakthrough series collaborative. January 4, 2017 Leape L, Kabcenell AI, Gandhi TK, et al. Reducing adverse drug events: lessons from a breakthrough series collaborative. Jt Comm J Qual Improv. 2000;26(6):321-31. https://psnet.ahrq.gov/issue/reducing-adverse-drug-event…

  9. Evidence for Advancing Heart Health | Agency for Healthcare Research and Quality

    www.ahrq.gov/evidencenow/projects/heart-health/evidence/index.html
    March 01, 2021 - Evidence for Advancing Heart Health Heart disease is the leading cause of death for men and women in the United States. To prevent heart attacks, health care professionals can work with their patients to adopt the ABCS of cardiovascular disease prevention: Aspirin use by high-risk individuals Blood press…

  10. Active Error (or Active Failure) | PSNet

    psnet.ahrq.gov/glossary/active-error-or-active-failure
    September 13, 2021 - Active Error (or Active Failure) September 13, 2021 Anonymous (not verified) The terms active and latent as applied to errors were coined by Reason . Active errors occur at the point of contact between a human and some aspect of a larger system (e.g., a human machine interface). They are generally readily …

  11. Substance-Related Inpatient Stays Across U.S. States and Counties (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/substance-abuse.pdf
    January 01, 2013 - Substance-Related Inpatient Stays Across U.S. States and Counties Substance-Related Inpatient Stays Across U.S. States and Counties From 2013-15, the national inpatient hospital rate was higher for alcohol use (588 stays per 100,000 population) than for opioids (217 per 100,000), cannabis (193 per 100,000 people)…

  12. Final Progress Report: Transdisciplinary Learning Lab To Eliminate Patient Harm and Reduce Waste (pdf file)

    www.ahrq.gov/sites/default/files/2025-03/sapirstein-report.pdf
    January 01, 2025 - Final Progress Report: Transdisciplinary Learning Lab To Eliminate Patient Harm and Reduce Waste Transdisciplinary Learning Lab to Eliminate Patient Harm and Reduce Waste Johns Hopkins Medicine Principal Investigator: Adam Sapirstein, MD Project Team Members: Ravi Aron, PhD Noah Barasch, MS Howard Carolan, MBA,…

  13. Communication: Obstetric Hemorrhage (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3-communication-speaker-notes.pdf
    July 01, 2023 - Errors caused by misunderstood dosage amounts or drugs with similar‐ sounding names were avoided. 23 … Furthermore, errors caused by misunderstood dosage amounts or drugs with similar‐sounding names were

  14. The Performance of Fusion Procedures for Degenerative Disease of teh Lumbar Spine (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/lumbar-fusion-protocol.pdf
    June 20, 2024 - • Neurogenic claudication: Pain or weakness in the legs during standing or walking, caused by nerve … • Radiculopathy: caused by a compressed nerve root that may result in pain, paresthesia, and reduced

  15. HEALTHCARE COST AND UTILIZATION PROJECT — HCUP (pdf file)

    hcup-us.ahrq.gov/db/nation/neds/NEDS2019Introduction.pdf
    September 01, 2021 - HEALTHCARE COST AND UTILIZATION PROJECT — HCUP HEALTHCARE COST AND UTILIZATION PROJECT — HCUP A FEDERAL-STATE-INDUSTRY PARTNERSHIP IN HEALTH DATA Sponsored by the Agency for Healthcare Research and Quality INTRODUCTION TO THE HCUP NATIONWIDE EMERGENCY DEPARTMENT SAMPLE (NEDS) 2019 These page…

  16. Approaches to Address Health Risks for Older Adults

    www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/about/ncepcr-older-adults-presentation.pptx
    March 15, 2025 - Because fragmentation is caused by many factors, no single intervention will fix the problem.

  17. A "Reflexive" Diagnosis in Primary Care | PSNet

    psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
    April 01, 2008 - SPOTLIGHT CASE A "Reflexive" Diagnosis in Primary Care Citation Text: Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: …

  18. Implementing a Fall Prevention Program | PSNet

    psnet.ahrq.gov/perspective/implementing-fall-prevention-program
    November 29, 2023 - Implementing a Fall Prevention Program Frances Healey, RN, PhD | December 1, 2011  View more articles from the same authors. Citation Text: Healey F. Implementing a Fall Prevention Program. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…

  19. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest | PSNet

    psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
    February 01, 2023 - SPOTLIGHT CASE When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Citation Text: Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.…

  20. Patient Safety Organizations: A Summary of 2014 Profiles (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
    January 01, 2014 - Patient Safety Organizations: A Summary of 2014 Profiles Patient Safety Organizations: A Summary of 2014 Profiles The safety of patients in health care settings remains a national priority and an important challenge. The Patient Safety Organization (PSO) program, which was authorized by the Patient Safety and Qu…
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