-
psnet.ahrq.gov/node/35707/psn-pdf
September 02, 2009 - What is Correct-Site Surgery?
September 2, 2009
American College of Surgeons.
https://psnet.ahrq.gov/issue/what-correct-site-surgery
This brochure provides information for patients to help ensure that their surgery is performed on the correct
part of the body.
https://psnet.ahrq.gov/issue/what-correct-site-surger…
-
psnet.ahrq.gov/node/45953/psn-pdf
July 22, 2020 - Root Cause Analysis in Health Care: A Joint Commission
Guide to Analysis and Corrective Action of Sentinel and
Adverse Events.
July 22, 2020
Oakbrook Terrace, IL: Joint Commission Resources; 2020. ISBN: 9781635851618.
https://psnet.ahrq.gov/issue/root-cause-analysis-health-care-joint-commission-guide-analysis-and-…
-
psnet.ahrq.gov/node/42515/psn-pdf
October 24, 2013 - Using four-phased unit-based patient safety walkrounds
to uncover correctable system flaws.
October 24, 2013
Taylor AM, Chuo J, Figueroa-Altmann A, et al. Using four-phased unit-based patient safety walkrounds to
uncover correctable system flaws. Jt Comm J Qual Patient Saf. 2013;39(9):396-403.
https://psnet.ahrq.g…
-
psnet.ahrq.gov/node/43393/psn-pdf
July 30, 2014 - Effectiveness of the surgical safety checklist in correcting
errors: a literature review applying Reason's Swiss
cheese model.
July 30, 2014
Collins SJ, Newhouse R, Porter J, et al. Effectiveness of the surgical safety checklist in correcting errors: a
literature review applying Reason's Swiss cheese model. AORN J…
-
psnet.ahrq.gov/node/37688/psn-pdf
April 16, 2008 - Role of registered nurses in error prevention, discovery
and correction.
April 16, 2008
Rogers AE, Dean GE, Hwang W-T, et al. Role of registered nurses in error prevention, discovery and
correction. Qual Saf Health Care. 2008;17(2):117-21. doi:10.1136/qshc.2007.022699.
https://psnet.ahrq.gov/issue/role-registered-…
-
digital.ahrq.gov/sites/default/files/docs/resource/Logan_ExcellenceReportQMs.pdf
June 16, 2021 - The Excellence Report: Quality Measures for Colonoscopy
The Excellence Report: Quality Measures for Colonoscopy
Quality Measure 1. Preprocedure risk assessment is documented.
Quality Measure 2. A management plan is documented for patients on oral anticoagulants.
Quality Measure 3. Sedation medication(s…
-
psnet.ahrq.gov/node/45949/psn-pdf
July 11, 2017 - Beyond medication reconciliation: the correct medication
list.
July 11, 2017
Rose AJ, Fischer SH, Paasche-Orlow MK. Beyond Medication Reconciliation: The Correct Medication List.
JAMA. 2017;317(20):2057-2058. doi:10.1001/jama.2017.4628.
https://psnet.ahrq.gov/issue/beyond-medication-reconciliation-correct-medicati…
-
psnet.ahrq.gov/node/50843/psn-pdf
January 29, 2020 - Incomplete Orders for Hypertonic Saline to Treat
Hyponatremia
January 29, 2020
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet].
2020.
https://psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
The Case
A 54-year-old man was brought t…
-
hcup-us.ahrq.gov/db/state/siddist/HI2011-2014SID_SEDD.pdf
December 15, 2016 - As part of the on-going HCUP quality management program, we discovered a problem with the
identification of Medicare patients in the 2011–2014 Hawaii State Inpatient Databases (SID) and
State Emergency Department Databases (SEDD). The purpose of this notification is to provide
a description of the issue and instruc…
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-215-depression-older-adults-comments.pdf
March 28, 2019 - CER 215 Adverse Effects of Pharmacologic Treatments of Major Depression in Older Adults
Comparative Effectiveness Review Disposition of Comments Report
Research Review Title: Adverse Effects of Pharmacologic Treatments of Major Depression
in Older Adults
Draft review available for public comment from May 13, 201…
-
hcup-us.ahrq.gov/db/state/siddist/2015NJSIDSASDSEDDDNR081608.pdf
June 01, 2018 - The 2015 HCUP Central Distributor State Inpatient Databases (SID), State Ambulatory Surgery
and Services Databases (SASD), and State Emergency Department Databases (SEDD) for
New Jersey were recreated in June 2018 to correct information in the data element containing
information about the patient’s Do Not Resuscitat…
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/fetal-surgery_disposition-comments.pdf
July 05, 2011 - Evidence-based Practice Center Systematic Review Protocol
Source: www.effectivehealthcare.ahrq.gov
Published Online: July 5, 2011
Technical Brief Research Review Disposition of Comments Report
Research Review Title: Maternal-Fetal Surgical Procedures
Draft review available for public comm…
-
hcup-us.ahrq.gov/db/state/siddist/IncorrectPayerMappings_IntramuralFiles.pdf
January 01, 2011 - The following States, years, and databases have the HCUP data element(s) for expected payer
(PAY1 and PAY2, if available) incorrectly assigned.
Hawaii 2011–2014 SID and SEDD
Kentucky 2008 SID
Texas 2004–2011 SID
The Hawaii SID and SEDD were corrected in 2017, but there are no plans to correct the
Kent…
-
www.uspreventiveservicestaskforce.org/uspstf/recommendation/impaired-visual-acuity-in-older-adults-screening-2009
July 15, 2009 - visual condition compared with ophthalmologic examination, and 1 study reported that geriatricians correctly
-
psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - Rethinking Root Cause Analysis
January 1, 2016
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
Annual Perspective 2016
Introduction
Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…
-
psnet.ahrq.gov/node/35692/psn-pdf
December 24, 2014 - Ensuring Correct Surgery.
December 24, 2014
National Center for Patient Safety; NCPS
https://psnet.ahrq.gov/issue/ensuring-correct-surgery
This pamphlet informs consumers on steps both patients and clinicians should take prior to surgery to
ensure safety.
https://psnet.ahrq.gov/issue/ensuring-correct-surgery
-
psnet.ahrq.gov/node/37009/psn-pdf
March 18, 2010 - Doing the "right" things to correct wrong-site surgery.
March 18, 2010
Patient Safety Advisory
https://psnet.ahrq.gov/issue/doing-right-things-correct-wrong-site-surgery
This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results
of other studies, and provides suggesti…
-
psnet.ahrq.gov/node/49791/psn-pdf
April 01, 2017 - Wrong-side Bedside Paravertebral Block: Preventing the
Preventable
April 1, 2017
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
The Case
An 84-year-old wo…
-
hcup-us.ahrq.gov/db/state/siddist/2010_2011ARSIDCDDoc071414.pdf
January 01, 2010 - The HCUP Central Distributor State Inpatient Databases (SID) for Arkansas 2010 and 2011
contain incorrect expected payer information for two hospitals in 2010 (exactly 4 percent of all
discharges) and five hospitals in 2011 (about one percent of all discharges). The 2010 and 2011
AR SID have been recreated with corr…
-
cds.ahrq.gov/sites/default/files/cds/artifact/1071/2024_Data_Requirements_Healthy_Diet_and_Physical_Activity.xlsx
January 01, 2024 - FHIR DSTU2 Data Requirements
FHIR DSTU2 Data Requirements: Healthy Diet and Physical Activity for CVD Prevention
This spreadsheet was created to assist with integration efforts (i.e., integrating the interoperable logic with a health IT system). It provides details about each clinical concept included in the CDS exp…