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4341. May I Have Another?—Medication Error | PSNet
      psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
      March 01, 2009 - May I Have Another?—Medication Error Citation Text: Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …

4342. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852698/psn-pdf
      August 30, 2023 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation August 30, 2023 https://psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and- diagnostic-accuracy Summary Addressing diagnostic errors to improve outcomes and patient safety h…

4343. Title Page (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015316-blair-final-report-2008.pdf
      January 01, 2008 - Title Page Grant Final Report Grant ID: 5UC1HS015316 Taconic Health Information Network & Community (THINC) Inclusive dates: 09/30/04 - 03/31/08 Principal Investigator: A. John Blair, III, MD Team members: Rainu Kaushal, MD (Co-Principal Investigator) Lisa M. Kern, MD (Investiga…

4344. The Case of Mistaken Intubation | PSNet
      psnet.ahrq.gov/web-mm/case-mistaken-intubation
      July 01, 2016 - SPOTLIGHT CASE The Case of Mistaken Intubation Citation Text: Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX End…

4345. Mnpoavideotranscript (pdf file)
      hcup-us.ahrq.gov/datainnovations/clinicaldata/MNPOAvideotranscript.pdf
      September 24, 2010 - Michael on screen:     Michael speaking:  My name is Michael Pine.  I’m an academic cardiologist who, for the past  two decades, has been developing and applying new methods of measuring and    improving clinical quality.  Today I’ll be sharing some information with you  about what we, as physicians, need to know abou…

4346. Frequently Asked Questions for Coronary Procedures Project
      hcup-us.ahrq.gov/datainnovations/clinicalcontentenhancementtoolkit/ny14.jsp
      September 01, 2014 - Frequently Asked Questions for Coronary Procedures Project An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FA…

4347. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72835/psn-pdf
      March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy March 10, 2021 In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy Editor’s Note: Libby Hoy, Patient Family Advisor (PFA), is the Founder and CEO of Patient Family Cente…

4348. Final Progress Report: Developing and Training Interruption Management Strategies for Emergency Physicians (pdf file)
      www.ahrq.gov/sites/default/files/2024-09/ratwani-report.pdf
      January 01, 2024 - Final Progress Report: Developing and Training Interruption Management Strategies for Emergency Physicians 1. TITLE PAGE Title: Developing and Training Interruption Management Strategies for Emergency Physicians Principal Investigator: Raj M. Ratwani, PhD Co-investigators: Zach Hettinger, MD, MS; Allan Fong, MS; T…

4349. Slippery Slide Into Life | PSNet
      psnet.ahrq.gov/web-mm/slippery-slide-life
      January 21, 2017 - Slippery Slide Into Life Citation Text: Halamek LP. Slippery Slide Into Life. 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 …

4350. Diagnostic Safety Resource List (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/diagnostic-safety-resources.pdf
      May 01, 2023 - Diagnostic Safety Resource List Improving Diagnostic Safety in Medical Offices: A Resource List for Users of the AHRQ Diagnostic Safety Supplemental Item Set I. Purpose This document provides a list of references to websites and other publicly available resources that medical offices can use to improve the ex…

4351. Final Progress Report: Changes in Hospital Care Organization and Outcomes (pdf file)
      www.ahrq.gov/sites/default/files/2024-09/kutney-lee-report.pdf
      January 01, 2024 - Final Progress Report: Changes in Hospital Care Organization and Outcomes 1. TITLE PAGE Title: Changes in Hospital Care Organization and Outcomes Principal Investigator: Ann Kutney-Lee Team Members: Linda H. Aiken (primary mentor); Jeffrey H. Silber, Mary Naylor, Ivo Abraham (co-mentors) Organization: University…

4352. Tool 11: Community Resource Guide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool11_comm_resource.docx
      June 02, 2025 - Tool 11: Community Resource Guide Tool 11: community resource guide Purpose Many hospital readmission reduction teams perceive that no community resources are available, even though community behavioral health and social service providers state they rarely receive referrals from hospitals. The purpose of this commu…

4353. How are CHIPRA quality demonstration States working together to improve the quality of health care for children? | Agency for Healthcare Research and Quality
      www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight06.html
      January 01, 2014 - How are CHIPRA quality demonstration States working together to improve the quality of health care for children? Evaluation Highlight No. 6 Authors: Dana Petersen, Henry Ireys, Grace Ferry, and Leslie Foster Contents Key Messages Background Findings Conclusion Implications Learn More Endno…

4354. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/overview-ptsoffventilator-facguide.docx
      January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle Slide Title and Commentary Slide Number and Slide Title Slide Overview: Getting Patients Off the Ventilator Faster SAY: In this module, we will introduce strategies and interventions, as well as adaptive and technical measures, which, when implemented, can help …

4355. Presentation: Program Overview
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/overview-ptsoffventilator-slides.pptx
      January 01, 2017 - Presentation: Program Overview Overview: Getting Patients Off the Ventilator Faster AHRQ Safety Program for Mechanically Ventilated Patients AHRQ Pub. No. 16(17)-0018-25-EF January 2017 Overview ‹#› AHRQ Safety Program for Mechanically Ventilated Patients 1 Learning Objectives After this session, you will be …

4356. Overview: Getting Patients Off the Ventilator Faster: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/vae/overview-off-ventilator-fac-guide.html
      February 01, 2017 - Overview: Getting Patients Off the Ventilator Faster: Facilitator Guide AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: Overview: Getting Patients Off the Ventilator Faster Say: In this module, we will introduce strategies and interventions, as well as adaptive and technical measures, …

4357. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49624/psn-pdf
      May 01, 2011 - Duty to Disclose Someone Else's Error? May 1, 2011 Gallagher TH. Duty to Disclose Someone Else's Error? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error Case Objectives State the rationale for disclosing medical errors. Describe key principles in effective error disclosure. …

4358. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49771/psn-pdf
      July 01, 2016 - Unintended Consequences of CPOE October 1, 2016 Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe Case Objectives Explain how technology, including computerized provider order entry, can transform, rather than eliminate, hazards. Recogni…

4359. Final Progress Report: Rural Healthcare Quality Network (RHQN) – AHRQ Grant Pre-Intervention Study Results (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/huck-report.pdf
      January 01, 2024 - Final Progress Report: Rural Healthcare Quality Network (RHQN) – AHRQ Grant Pre-Intervention Study Results Rural Healthcare Quality Network (RHQN) – Agency for Healthcare Research and Quality Grant FINAL REPORT BACKGROUND Purpose of the Study The purpose of the study was to examine clinician’s attitudes and p…

4360. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49855/psn-pdf
      March 01, 2019 - Which Line: Ordering Provider or Proceduralist? March 1, 2019 Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist Case Objectives Review the role of mistake-proofing to block errors from leading to adverse…