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8341. Undetected Foreign Object | PSNet
      psnet.ahrq.gov/web-mm/undetected-foreign-object
      April 24, 2018 - Undetected Foreign Object Citation Text: Cima RR. Undetected Foreign Object. 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 tagged P…

8342. Module-3-Implementation-Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-3-implementation-guide.pdf
      June 02, 2025 - 1 Implementation Guide - Module 3 Understanding your Workflow Processes to Prepare for Systems Change Module Purpose This module continues the discussion of the steps necessary for systems change to support the implementation of automatic referral with effective care coordination. Topics include the “w…

8343. Implementing Team Approaches for Improving Diabetes Care in Health Centers | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/delivery-initiative/rodriguez/index.html
      December 01, 2020 - Implementing Team Approaches for Improving Diabetes Care in Health Centers Slide Presentation by Hector P. Rodriguez Text version of a slide presentation made by Hector P. Rodriguez, PhD, MPH. Sign up: Quality Measure Tools Email updates Slide 1 Implementing Team Approaches for Improving Diabetes Ca…

8344. Chapter 3. Developing Change: Designing the Medication Reconciliation Process | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/patient-safety/settings/hospital/match/chapter-3.html
      July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation Chapter 3. Developing Change: Designing the Medication Reconciliation Process Previous Page Next Page Table of Contents Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Recon…

8345. Chapter 3. Developing Change: Designing the Medication Reconciliation Process | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/match/chapter-3.html
      July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation Chapter 3. Developing Change: Designing the Medication Reconciliation Process Previous Page Next Page Table of Contents Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Recon…

8346. An Overview of the CANDOR Process
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module8/module8-organizational-learning-sustainability.pptx
      August 20, 2015 - An Overview of the CANDOR Process Communication and Optimal Resolution (CANDOR) Toolkit Module 8: Organizational Learning and Sustainability Module 8, the last module in the CANDOR Toolkit, provides an overview of organizational learning and how an organization can develop a sustainability plan to assure the CAND…

8347. NAA National Webinar August 2024 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/action-alliance-webinar-august-2024.pdf
      January 01, 2024 - NAA National Webinar August 2024 Empowering Frontline Staff with Competencies for Patient Safety NATIONAL WEBINAR SERIES August 20, 2024 Housekeeping Instructions • This webinar will be recorded and available for viewing on the NAA website • Please use the ‘Chat’ function to engage with us throughout to webina…

8348. Patient Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/reports/2025-annual-report/patient-safety.html
      August 01, 2025 - AHRQ’s Investments in Primary Care Research for 2023 and 2024 Patient Safety Previous Page Next Page Table of Contents AHRQ’s Investments in Primary Care Research for 2023 and 2024 Acknowledgements and Authors Message from the Director of AHRQ’s National Center for Excellence in Primary Care R…

8349. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities | PSNet
      psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
      November 27, 2019 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities Citation Text: Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…

8350. Table of Contents: Volume 1. Assessment (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/TableofContents_Vol1.pdf
      January 01, 2025 - Table of Contents: Volume 1. Assessment Contents Volume 1. Assessment Prologue: Laying the Foundation Kerm Henriksen Looking Forward, Benefiting from the Past Envisioning Patient Safety in the Year 2025: Eight Perspectives Kerm Henriksen, Caitlin Oppenheimer, Lucian Leape, et al. What Exactly Is Patien…

8351. Discharge Fumbles | PSNet
      psnet.ahrq.gov/web-mm/discharge-fumbles
      September 09, 2009 - SPOTLIGHT CASE Discharge Fumbles Citation Text: Forster AJ. Discharge Fumbles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

8352. Impact of Staff-Led Safety Walk Rounds (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Montgomery_42.pdf
      March 05, 2008 - Impact of Staff-Led Safety Walk Rounds Impact of Staff-Led Safety Walk Rounds Vicki L. Montgomery, MD, FAAP, FCCM Abstract Objectives: The primary objectives of this study were to provide a venue for discussing safety concerns and to facilitate finding solutions for everyday safety issues. Methods: The mul…

8353. Table of Contents: Volume 4. Technology and Medication Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/TableofContents_Vol4.pdf
      January 01, 2025 - Table of Contents: Volume 4. Technology and Medication Safety Contents Volume 4. Technology and Medication Safety Prologue: Technology and Medication Safety Mary L. Grady Health Information Technology “Safeware”: Safety-Critical Computing and Health Care Information Technology Robert L. Wears, Nancy G. Lev…

8354. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. | PSNet
      psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
      May 01, 2005 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. Citation Text: Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…

8355. Techno Trip | PSNet
      psnet.ahrq.gov/web-mm/techno-trip
      May 01, 2005 - Techno Trip Citation Text: Cook RI. Techno Trip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Downlo…

8356. Mutual Support: Obstetric Hemorrhage (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_5-mutual-support-speaker-notes.pdf
      July 01, 2023 - It is especially helpful for communicating feedback constructively and effectively managing and resolving

8357. Mutual Support: Obstetric Hemorrhage - PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_5-mutual-support.pptx
      July 01, 2023 - It is especially helpful for communicating feedback constructively and effectively managing and resolving

8358. Mathews, Craig | Digital Healthcare Research
      digital.ahrq.gov/principal-investigator/mathews-craig
      January 01, 2023 - Mathews, Craig Service Integration - Final Report Citation Mathews C. Service Integration - Final Report. (Prepared by Franklin Foundation Hospital under Grant No. UC1 HS016151). Rockville, MD: Agency for Healthcare Research and Quality, 2008. Principal Investigator …

8359. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44232/psn-pdf
      January 29, 2019 - Optimizing medication safety in the home. January 29, 2019 LeBlanc RG, Choi J. Optimizing medication safety in the home. Home Healthc Now. 2015;33(6):313-319. doi:10.1097/NHH.0000000000000246. https://psnet.ahrq.gov/issue/optimizing-medication-safety-home Patients who receive home care services are vulnerable to a…

8360. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60527/psn-pdf
      May 27, 2020 - The flaw of medicine: addressing racial and gender disparities in critical care. May 27, 2020 Hilton EJ, Goff KL, Sreedharan R, et al. The flaw of medicine: addressing racial and gender disparities in critical care. Anesthesiol Clin. 2020;38(2):357-368. doi:10.1016/j.anclin.2020.01.011. https://psnet.ahrq.gov/issu…