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www.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-case-study-risk-screening.pdf
June 02, 2025 - Implementing Opioid Risk Screening for Older Adults Using Automated Patient Reminders in an Electronic Health Record Case Study
1
Intervention: Many older adults experience chronic pain that
requires long term opioid therapy (LTOT). The physician- owner,
who also acts as a quality improvement (QI) lead at Pearl
F…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/169-cusp-science-safety-slides.pptx
October 01, 2024 - patients are harmed during a hospital stay.1
Preventable patient error is among the leading causes of death … What are some of the system factors that contributed to Susan’s death?
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/smoking-use-ready-or-not.pdf
June 02, 2025 - Quit Line and the fax referral option.
5 Cigarette Smoking — A Leading Cause of Preventable Death … MDiv, CTTS
3 Patient Case Study
4 Objectives
5 Cigarette Smoking — A Leading Cause of Preventable Death
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www.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-refs.html
September 01, 2013 - Risk of infection and death due to Methicillin-resistant Staphylococcus aureus in long-term carriers
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4i_combo_psi12-dvt-bestpractices.pdf
May 20, 2016 - vein thrombosis (DVT) and pulmonary embolism (PE) constitute the largest
cause of preventable hospital death
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www.ahrq.gov/hai/clabsi-tools/appendix-2.html
March 01, 2018 - Appendix 2. Central Line-Associated Bloodstream Infections Fact Sheet
Tools for Reducing Central Line-Associated Blood Stream Infections
These tools will help your unit implement evidence-based practices and eliminate central line-associated blood stream infections (CLABSI). When used with the CUSP (Comprehen…
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www.ahrq.gov/funding/grantee-profiles/grtprofile-schoenthaler.html
March 01, 2024 - Chronic conditions such as heart disease, diabetes, and stroke are the leading causes of disability and death
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www.ahrq.gov/sites/default/files/wysiwyg/topics/impact-opioid-final.pdf
November 01, 2018 - Opioids AHRQ Works: Building Bridges Between Research and Practice
Opioids
Deaths from drug overdoses have risen steadily over the
past 2 decades. The misuse of opioids, such as
prescription pain medications and heroin, has become
widespread across the United States. In response to
dramatic increa…
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www.ahrq.gov/sites/default/files/2025-02/weekes-report.pdf
January 01, 2025 - Primary outcome was a composite of death, delayed
circulatory or respiratory dysfunction, respiratory … The primary outcome was a composite of death, delayed circulatory or respiratory
dysfunction, hypoxia … Measures
The primary composite outcome was death (all cause or PE-related) or clinical deterioration … Deaths were classified as PE-related when the site
investigator reviewed the case and determined death … downward reclassifications by PE-SCORE
followed by determination of prognostic errors or corrections for death
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www.ahrq.gov/sites/default/files/2025-03/blike-report.pdf
January 01, 2025 - they recognize and manage complications once they occur.5 Thus, minimizing “failure to
rescue” (i.e., death … HERT 520
Code Blue 322
Stat airway 79
Mortality, Percent 2.73%
AHRQ Safety indicator PSI4:
Death … The analysis found one death
due to sedative/analgesic medication administration when surveillance monitoring … The reduced death rate when
surveillance monitoring was available (0.0009%) versus not available (0.02% … discriminate p atients at risk of early cardiac arrest, unanticipated intensive
care unit admission, and death
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-final-es-cs061721.pdf
December 01, 2020 - 2019 National Healthcare Quality and Disparities Report Executive Summary
2019
NATIONAL
HEALTHCARE
QUALITY &
DISPARITIES
REPORT
Executive Summary
2019
This document is in the public domain and may be used and reprinted without
permission. Citation of the source is appreciated. Suggested citation: 2019 Nati…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-science-safety.pptx
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Under the Science of Safety
AHRQ Safety Program for Perinatal Care
Understand the Science of Safety for Perinatal Safety
AHRQ Publication No. 17-0003-4-EF
May 2017
1
Learning Objectives
2
AHRQ Safety Program for Perinatal Care
Science of S…
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www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/hisph-slides.html
March 01, 2020 - Slide 21
Priorities of the Heckler Report
Focused on six causes of death with large Black-White … This system classifies Hispanics as Whites, so no death statistics on Hispanics are presented. … Today, death statistics on Hispanics are available. … Rates of diagnosis with advanced stage breast cancer and death due to breast cancer were lower among … Groups With Disparities:
Death rates were lower among Hispanics compared with Whites and were not
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www.ahrq.gov/hai/pfp/interimhac2013-ref.html
December 01, 2014 - Preventing maternal death. Sentinel Event Alert Issue 44; January 26, 2010.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4_pdi_bestpracticescover.pdf
June 02, 2025 - why best practices were not developed:
• NQI 02 Neonatal Mortality Rate: This PDI relates to the death
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-k.pdf
June 02, 2025 - Healthcare-associated
infections (HAIs) are a
significant cause of
illness, death, and
excess
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www.ahrq.gov/news/blog/ahrqviews/portrait-of-sepsis.html
September 01, 2024 - untreated infection, causing the body to attack itself, leading to tissue damage, organ failure, and often death
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apa.pdf
June 02, 2025 - ■ “SIDS” stands for Sudden Infant Death Syndrome. … ■ Sudden, unexplained death of an infant less than 1
year old.
What should I know about SIDS?
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-medication-chartbook-2024.pdf
January 01, 2024 - Scale provides the following possible
responses: No harm, Mild harm, Moderate harm, Severe harm, Death … the EXTENT OF HARM is categorized as No
harm, Harm (i.e., Mild harm, Moderate harm, Severe harm, or Death … event reached the patient, but no harm was evident, and Harm,
which encompasses events resulting in death … HARM reported are displayed as either No harm, Harm (i.e., Mild harm,
Moderate harm, Severe harm, or Death
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www.ahrq.gov/hai/cusp/national/index.html
December 01, 2016 - National Implementation Project Reports
Central Line Insertion Care Team Checklist
Checklist developed by Johns Hopkins Medicine that provides critical steps to reduce HAIs.
Ending Healthcare-Associated Infections
Fact sheet that provides an overview of CUSP and highlights AHRQ-supporte…