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5441. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44414/psn-pdf
      July 01, 2017 - From a reactive to a proactive safety approach. Analysis of medication errors in chemotherapy using general failure types. July 1, 2017 Fyhr A, Ternov S, Ek Å. From a reactive to a proactive safety approach. Analysis of medication errors in chemotherapy using general failure types. Eur J Cancer Care (Engl). 2017;2…

5442. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853236/psn-pdf
      September 06, 2023 - Video review of simulated pediatric cardiac arrest to identify errors/latent safety threats: a mixed methods study. September 6, 2023 Garcia-Jorda D, Nikitovic D, Gilfoyle E. Video review of simulated pediatric cardiac arrest to identify errors/latent safety threats: a mixed methods study. Simul Healthc. 2023;18(4…

5443. 30-Day Readmission Rates to U.S. Hospitals, 2010 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/readmission-rates.pdf
      June 02, 2025 - 30-Day Readmission Rates to U.S. Hospitals, 2010 Medicare Medicaid Privately Insured Uninsured Medicaid Medicare Privately Insured Uninsured 30-DAY READMISSION RATES TO U.S. HOSPITALS *Readmissions were for all causes and did not necessarily include the same procedure or diagnosis as the original admission (…

5444. Flu's Annual Impact (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/flus-annual-impact.pdf
      October 01, 2019 - Flu's Annual Impact for ambulatory visits* $312 Hospital Inpatient Stays per 100,000 people Flu’s Annual Impact The influenza virus causes respiratory illness in both children and adults. Severe cases may result in hospitalizations and even death, but even mild cases often require treatment. Recen…

5445. Flu's Annual Impact (pdf file)
      hcup-us.ahrq.gov/reports/infographics/flus-annual-impact.pdf
      October 01, 2019 - Flu's Annual Impact for ambulatory visits* $312 Hospital Inpatient Stays per 100,000 people Flu’s Annual Impact The influenza virus causes respiratory illness in both children and adults. Severe cases may result in hospitalizations and even death, but even mild cases often require treatment. Recen…

5446. In Conversation With… Andrew Gettinger, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
      September 01, 2017 - Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy … 2019 Orders on file but no labs drawn: investigation of machine and human errors caused

5447. In Conversation With... Anna Legreid Dopp, Pharm. D | PSNet
      psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d
      June 29, 2020 - Today during COVID, many of the shortages are being caused by the sharp increases in demand due to the

5448. Aspirin Use to Prevent Cardiovascular Disease: US Preventive Services Task Force Recommendation Statement (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/LPaUxRbrTshfsYVVTzenEQ
      April 26, 2022 - note that it did not review the emerging evidence on the effect of aspirin on COVID-19, the disease caused

5449. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/creating-safety-culture/cultureofsafety_hemodialysis.pptx
      September 03, 2014 - outcomes such as harms (harming a patient) or adverse events (anything unwanted, even if no harm is caused … primarily embodies adaptive work, in which teams help staff understand the results of preventable harm caused

5450. Workarounds and Resiliency on the Front Lines of Health Care | PSNet
      psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
      August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health Care Anita L. Tucker, DBA, MS | August 1, 2009  Also Read a Conversation View more articles from the same authors. Citation Text: Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSN…

5451. AHRQ Evidence-Based Practice Center (EPC) Program Research Gaps Summary: Pain Management (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/gaps-pain-management.pdf
      January 01, 2023 - AHRQ Evidence-Based Practice Center (EPC) Program Research Gaps Summary: Pain Management AHRQ EVIDENCE-BASED PRACTICE CENTER (EPC) PROGRAM RESEARCH GAPS SUMMARY: PAIN MANAGEMENT An AHRQ EPC publication summarizing evidence gaps identified across recent EPC reviews for select healthcare topics addressing the …

5452. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations | PSNet
      psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
      September 27, 2023 - SPOTLIGHT CASE Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations Citation Text: Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. PSNet [internet]. Agency for Healthcare Research and Qu…

5453. Primary Care Practice Facilitation Curriculum Module 9: Using Appreciative Inquiry with Practices (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-9-appreciative-inquiry.pdf
      September 01, 2015 - Primary Care Practice Facilitation Curriculum Module 9: Using Appreciative Inquiry with Practices Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov Primary Care Practice Facilitation Curriculum Module 9: Using Appreciative Inquiry with Practices …

5454. Making Healthcare Safer Practices: 11. Patient Identification Errors in the Operating Room (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/patient-id-errors-1.pdf
      March 01, 2020 - Making Healthcare Safer Practices: 11. Patient Identification Errors in the Operating Room Patient Identification Errors in the Operating Room 11-1 11. Patient Identification Errors in the Operating Room Authors: Cori Sheedy, Ph.D., and Sonja Richard, M.P.H. Introduction In the first Making Health Care Safer …

5455. Hospitalizations Involving Mental and Substance Use Disorders Among Adults, 2012 (pdf file)
      hcup-us.ahrq.gov/reports/statbriefs/sb191-Hospitalization-Mental-Substance-Use-Disorders-2012.pdf
      January 01, 2012 - Hospitalizations Involving Mental and Substance Use Disorders Among Adults, 2012 1 June 2015 Hospitalizations Involving Mental and Substance Use Disorders Among Adults, 2012 Kevin C. Heslin, Ph.D., Anne Elixhauser, Ph.D., and Claudia A. Steiner, M.D., M.P.H. Introduction Mental and…

5456. On-Time Falls Prevention | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/packet.html
      November 01, 2017 - On-Time Falls Prevention Overview Materials Packet Samples of four types of reports are provided here: On-Time Falls High-Risk Report . Quarterly Summary of Falls Risk Factors by Unit or Facility . Monthly Contextual Factors Report . Postfall Assessment Summary Report .   On-Time Falls High-Ri…

5457. Evaluation and Integration of an Automatic Fall Prediction System - 2012 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/evaluation-and-integration-automatic-fall-prediction-system/annual-summary/2012
      January 01, 2012 - Evaluation and Integration of an Automatic Fall Prediction System - 2012 Project Name Evaluation and Integration of an Automatic Fall Prediction System Principal Investigator Kearns, William D. Organization University of South Florida Funding Mechanism PAR: HS08-269…

5458. Using Aspirin for the Primary Prevention of Cardiovascular Disease (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/4fdC2JLwP_um_yZe4WZRaa
      April 01, 2009 - Using Aspirin for the Primary Prevention of Cardiovascular Disease How do I determine benefit? An individual’s potential clinical benefit from aspirin depends on his or her baseline risk. MI Risk Factors for Men y Age y Diabetes y Total cholesterol level y HDL cholesterol level y High blood pressure y Smok…

5459. 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-blank-template.pptx
      June 02, 2025 - Improving Communication and Teamwork in the Surgical Environment Quality Improvement Study Template Ambulatory Surgery Center AHRQ Safety Program for Ambulatory Surgery Implementation Guide Appendix K. Quality Improvement Study Framework Quality Improvement Study Templat…

5460. BLADDER SCAN – POLICY #2202 12/11/06 (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/cauti-surveillance/review-form.docx
      March 01, 2017 - BLADDER SCAN – POLICY #2202 12/11/06 Appendix K. CAUTI Case Review Form Purpose The CAUTI Case Review Form is a performance improvement look-back tool that assists long-term care (LTC) facilities with identifying possible resident care issues that might have contributed to a catheter-associated urinary tract infecti…