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7581. Disposition of Comments_Comparative Effectiveness Review No. 274: Diagnosis and Treatment of Tethered Spinal Cord (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-274-tethered-spinal-cord-disposition-comments.pdf
      October 25, 2024 - Disposition of Comments_Comparative Effectiveness Review No. 274: Diagnosis and Treatment of Tethered Spinal Cord Comparative Effectiveness Review Disposition of Comments Report Title: Diagnosis and Treatment of Tethered Spinal Cord Draft report available for public comment from February 23, 2024, to…

7582. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853773/psn-pdf
      September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side. September 27, 2023 Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side The Case A first-year orthopedic surgery resident was consulted…

7583. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49676/psn-pdf
      February 01, 2013 - Death by PCA February 1, 2013 Hicks RW. Death by PCA. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/death-pca The Case A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …

7584. Integrating Teamwork Tools into CUSP Efforts | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/integrating-teamwork-tools-cusp-efforts-transcript.html
      December 01, 2017 - Integrating Teamwork Tools into CUSP Efforts Webinar Transcript On the CUSP: Stop CAUTI in the ED ED Mini-Presentation to Accompany April 7, 2015 ED Coaching Call Sarah:  Hello, everyone, and thank you for listening today. My name is Sarah Dalton and I am a research specialist with the Health Research and…

7585. Integrating-Teamwork-Tools-Into-Cusp-Efforts-Transcript (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/integrating-teamwork-tools-into-cusp-efforts-transcript.docx
      April 07, 2015 - On the CUSP: Stop CAUTI in the ED ED Mini-Presentation to Accompany April 7, 2015 ED Coaching Call Sarah: Hello, everyone, and thank you for listening today. My name is Sarah Dalton and I am a research specialist with the Health Research and Educational Trust. Welcome to the second mini-presentation in the CAUTI ED …

7586. Guide to Sustaining a Program To Reduce Catheter-Associated Urinary Tract Infections in Long-Term Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/sustainability/sustaining-guide.pdf
      March 01, 2017 - Guide to Sustaining a Program To Reduce Catheter-Associated Urinary Tract Infections in Long-Term Care AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Guide to Sustaining a Program To Reduce Catheter-Associated Urinary Tract Infections in Long-Term Care AHRQ Public…

7587. Toolkits | PSNet
      psnet.ahrq.gov/toolkits
      March 01, 2025 - Toolkits Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols. Want to submit a Toolkit? Has your organization deve…

7588. Research Overview | Digital Healthcare Research
      digital.ahrq.gov/program-overview/research-reports/2021-year-review/research-overview
      January 01, 2021 - Research Overview Digital healthcare knowledge and tools can enhance the efforts of patients, clinicians, and health systems working to improve healthcare quality and safety. AHRQ’s DHR program funds research to create actionable findings on what and how digital healthcare works best for t…

7589. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
      August 01, 2022 - Implementation Guide for the CANDOR Process Communication and Optimal Resolution Toolkit Purpose: The Toolkit Implementation Guide is a reference for organizational leaders who are committed to improving their response to unexpected patient harm events. The guide describes the CANDOR process, implementatio…

7590. Check Twice, Transport Once | PSNet
      psnet.ahrq.gov/web-mm/check-twice-transport-once
      March 15, 2023 - Check Twice, Transport Once Citation Text: DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

7591. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49698/psn-pdf
      December 01, 2013 - SNFs: Opening the Black Box December 1, 2013 Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/snfs-opening-black-box The Case An 88-year-old woman was admitted to a skilled nursing facility (SNF) after a lengthy hospitalization for a small bowel obstructio…

7592. Advances in Patient Safety: New Directions and Alternative Approaches | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/advances-new-directions/index.html
      July 01, 2022 - Advances in Patient Safety: New Directions and Alternative Approaches Advances in Patient Safety: New Directions and Alternative Approaches represents years of study by AHRQ-funded patient safety researchers and others. It includes articles on reporting systems, risk assessment, safety culture, m…

7593. Slow Down: Right Drug, Wrong Formulation | PSNet
      psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
      October 13, 2018 - Slow Down: Right Drug, Wrong Formulation Citation Text: Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndN…

7594. A National Web Conference on the Use of Health IT to Improve Care Planning and Communication With Aging Adults - Slides (pdf file)
      digital.ahrq.gov/sites/default/files/docs/hit-aging-adults-slides-071717.pdf
      July 17, 2017 - A National Web Conference on the Use of Health IT to Improve Care Planning and Communication With Aging Adults - Slides 1 A National Web Conference on the Use of Health IT to Improve Care Planning and Communication With Aging Adults Presented by: David H. Gustafson, Ph.D. Charles Safran, M.D., M.S., FACMI Kevi…

7595. Strategy 6K: Cultivating Cultural Competence | Agency for Healthcare Research and Quality
      www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/communication/strategy6kculturalcompetence.html
      March 01, 2020 - Strategy 6K: Cultivating Cultural Competence Contents 6.K.1. The Problem 6.K.2. Interventions    6.K.2.a. Maintaining Complete and Accurate Information on Enrollees    6.K.2.b. Building a Provider Network to Meet the Community’s Linguistic and Cultural Needs    6.K.2.c. Training Providers on Cultural…

7596. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863650/psn-pdf
      February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance Measurement Tracking, and Performance Feedback February 28, 2024 https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking- and-performance Summary To improve patient care and outcomes in the intensive care unit (ICU…

7597. 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…

7598. Making Healthcare Safer Practices: 15. Care Transitions (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/care-transitions-1.pdf
      March 01, 2020 - • Shared Accountability Across Providers and Organizations: Enhancing the transition of care process … Shared Accountability Across Providers and Organizations Enhancing the transition of care process … Enhancing the care transitions intervention protocol to better address the needs of family caregivers … Enhancing the care transitions intervention protocol to better address the needs of family caregivers

7599. 3. Breadth and Focus Areas of Federal Agency Research Portfolios in HSR and PCR | Agency for Healthcare Research and Quality
      www.ahrq.gov/healthsystemsresearch/hspc-research-study/breadth-and-focus.html
      July 01, 2021 - risk for illness or disability, including specific populations (children, aged, and minorities) Enhancing … National Institutes of Health Enhancing health of the nation with a focus on specific diseases, body

7600. High-Risk Deliveries at Facilities With 24/7 In-House Physician Capable of Safely Managing Labor and Delivery and Performing a Cesarean Section, Including an Emergent Cesarean Section (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-0120-fullreport.pdf
      May 01, 2018 - High-Risk Deliveries at Facilities With 24/7 In-House Physician Capable of Safely Managing Labor and Delivery and Performing a Cesarean Section, Including an Emergent Cesarean Section 1 High-Risk Deliveries at Facilities with 24/7 In-House Physician Capable of Safely Managing Labor and Delivery and Performing a …