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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
March 12, 2008 - Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes
Evaluation of Medications Removed from Automated
Dispensing Machines Using the Override Function
Leading to Multiple System Changes
Karla Miller, PharmD; Manisha Shah, MBA, RT; Lau…
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www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-cognitive-load-theory.pdf
May 01, 2024 - Cognitive Overload
Cognitive overload occurs when working memory becomes overly burdened, leading to a decreased … As discussed above, cognitive overload
is associated with decreased cognitive flexibility and more simplistic
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www.ahrq.gov/sites/default/files/2025-03/toledo-report.pdf
January 01, 2025 - Larger decreases in blood pressure
may cause an increased incidence of nerve injury due to decreased
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www.ahrq.gov/hai/cauti-tools/archived-webinars/preventing-cauti-focus-procedure-related-transcript.html
December 01, 2017 - Overall, the urinary tract infection rate was decreased 86 percent among those with early removal of … On our surgery ward, dramatically decreased as did our device utilization.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-focus-procedure-related-cath-use-transcript.doc
July 08, 2014 - Overall, the urinary tract infection rate was decreased 86 percent among those with early removal of … On our surgery ward, dramatically decreased as did our device utilization.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/respiratory-one-pager.pdf
September 01, 2022 - Upper Respiratory Tract Infection: The Common Cold
Diagnosis
• Upper respiratory tract infections or “the common cold” are caused by viruses and present with symptoms
such as rhinorrhea, sneezing, sinus congestion, sore throat, cough, low-grade fever, headache, and
fatigue.
• The common cold occurs…
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www.ahrq.gov/news/newsroom/case-studies/ktcquips87.html
October 01, 2014 - Six Texas Hospitals Improve Care With AHRQ Medication Reconciliation Toolkit
Search All Impact Case Studies
November 2011
Between January and September 2010, AHRQ partnered with seven Quality Improvement Organizations (QIOs) to deliver a series of onsite learning sessions and provider support calls focusing…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case3.html
November 01, 2014 - reflected in patient surveys, which increased in the first quarter after the cardiology project but decreased … They specifically pointed to improved satisfaction due to decreased patient wait times in the laboratory … safety improvements as a result of this process and also noted that phone calls from patients to nurses decreased
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie-2025.pdf
January 01, 2025 - they obtained preliminary evidence that organizational
changes and academic detailing significantly decreased … The average adjusted “face-to-face” time spent per
patient decreased slightly, but the decrease (0.41 … Medication administration errors decreased,
and few pump-related errors were made.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/121-importance-mrsa-prevention-one-pager.docx
April 01, 2025 - Surgical Site Infection (SSI) Facts
SSIs account for 20 percent of all healthcare-associated infections.1
SSIs are a major cause of morbidity and mortality.2
SSIs lead to rehospitalization and increased costs ($3–10 billion annually).2,3
SSIs due to MRSA lead to higher morbidity and mortality.4
Staphylococcus aureus an…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/018-ss-importance-ssi-mrsa-prevention.pptx
April 01, 2025 - Underlying illness
Surgical procedures
Decreased natural defenses
Invasive disease and MRSA infection
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man1.html
December 01, 2017 - Decreased ability to function.
Serious injuries.
Increased risk of death.
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www.ahrq.gov/sites/default/files/2024-01/thamer-report.pdf
January 01, 2024 - for anemia
Anemia affects nearly all patients with ESRD and results in reduced quality of life and
decreased … Despite the increasing evidence that ESA therapy has serious side
effects and might be associated with decreased … EPOGEN® (Epoetin alfa) sales decreased 27 percent to $476 million in the third quarter of
2011 reflecting
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www.ahrq.gov/sites/default/files/2024-04/levett-report.pdf
January 01, 2024 - Percent of INRs in range improved from 49% to 65%; the number
of times a nurse contacted a physician decreased … from a high of 20% to 1%; the percent of INRs >
5 decreased from 3% to 1%.
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www.ahrq.gov/ncepcr/about/pcr-webinar-series/research-pc-workforce.html
May 01, 2024 - Research Methods for Studying the Primary Care Workforce
AHRQ’s National Center for Excellence in Primary Care Research presented a webinar on Research Methods for Studying the Primary Care Workforce . Three AHRQ grantees who have developed methodologies to understand the optimal structure and composition of p…
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www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/appa.html
August 01, 2022 - The proportion of claims that were dismissed decreased (34% vs. 22%; p=.001), but the proportion of claims … Mean payments decreased from $290,992 to $90,429 (p<.001). … The time from the event to a claim decreased, but there was no significant change in the time from a … Further, incidents of shoulder dystocia and fetal distress decreased 50% (Santos, Ritter, Hefele, et … from 155 to 54 and rates of serious potential safety risk decreased from 28 to 13 (p<.05).
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www.ahrq.gov/hai/tools/cauti-hospitals/toolkit-use.html
December 01, 2017 - How To Use the Toolkit for Reducing CAUTI in Hospitals
Toolkit for Reducing CAUTI in Hospitals
The toolkit consists of three modules–Implementation, Sustainability, and Resources—that a hospital unit can use to teach team members specific ways to adopt best practices regarding CAUTI prevention. Use of this to…
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www.ahrq.gov/hai/tools/mvp/modules/vae/surveillance-fac-guide.html
February 01, 2017 - Ventilator-Associated Event Surveillance: Facilitator Guide
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: Ventilator-Associated Event Surveillance
Say:
This module will focus on ventilator-associated event surveillance and how it can be used in your unit.
Slide 2: Learning Objectiv…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-sops-riverside-handoffs-webcast-hansford.pdf
January 01, 2023 - communicat ion between each
other and w/ patients/fami lies
Loss of t rust from pat ients/famil ies
Decreased
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www.ahrq.gov/sites/default/files/2025-02/goldman-report.pdf
January 01, 2025 - risk-adjusted mortality, we found that the percentage of hospitals whose rank
differed (either increased or decreased … experienced a difference in ranking of at least 10%; 12.5% increased
rank by greater than 10%, and 12.4% decreased … under-reporting of POA, 20.8% of the hospitals’
rank differed; 10.8% increased in rank >10%, and 10.0% decreased