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hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/fl9.jsp
August 01, 2014 - Linking Maternal and Child Health Data to Create a Comprehensive Longitudinal Dataset: The Florida Experience.
An official website of the Department of Health & Human Services
Search All AHRQ Websit…
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hcup-us.ahrq.gov/datainnovations/clinicalcontentenhancementtoolkit/fl9.jsp
August 01, 2014 - Linking Maternal and Child Health Data to Create a Comprehensive Longitudinal Dataset: The Florida Experience.
An official website of the Department of Health & Human Services
Search All AHRQ Websit…
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digital.ahrq.gov/ahrq-funded-projects/utilizing-health-information-technology-improve-health-care-quality
January 01, 2023 - Utilizing Health Information Technology to Improve Health Care Quality
Project Final Report ( PDF , 395.03 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent t…
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digital.ahrq.gov/sites/default/files/docs/resource/Real_Time_and_On_Time_Lessons_Learned_9_6_06.pdf
June 16, 2021 - lessons learned, successes, and barriers for the ‘Real-Time’ and QIO ‘ON-Time’ projects
1
LESSONS LEARNED, SUCCESSES, AND BARRIERS FOR THE
‘REAL-TIME’ AND QIO ‘ON-TIME’ PROJECTS
LESSONS LEARNED
1. Partnerships are effective to initiate and support change.
Partnerships within facilities (multi-disciplina…
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psnet.ahrq.gov/node/33778/psn-pdf
March 01, 2015 - Diagnostic Errors
January 1, 2014
Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/diagnostic-errors
Annual Perspective 2014
Until very recently, diagnostic errors received relatively little attention in the field of patient safety,
particularly when compared wi…
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psnet.ahrq.gov/node/49503/psn-pdf
February 01, 2006 - Workaround Error
February 1, 2006
Pape T. Workaround Error. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/workaround-error
The Case
A retired 81-year-old physician with metastatic colon cancer was admitted to an acute care hospital with
pneumonia and congestive heart failure (CHF). After his acute hospita…
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psnet.ahrq.gov/node/49730/psn-pdf
April 01, 2015 - Transition to Nowhere
April 1, 2015
Farrell TW. Transition to Nowhere. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/transition-nowhere
The Case
A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension,
and chronic kidney disease was admitted to the hospital …
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digital.ahrq.gov/barriers-hit-implementation
January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…
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psnet.ahrq.gov/node/49488/psn-pdf
August 21, 2005 - PCA Overdose
August 21, 2005
Doyle JD. PCA Overdose. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pca-overdose
The Case
A 49-year-old woman underwent an uneventful total abdominal hysterectomy bilateral salpingo-
oophorectomy. Postoperatively, the patient complained of severe pain and received intravenou…
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psnet.ahrq.gov/node/49697/psn-pdf
December 01, 2013 - Check the Anesthesia Machine
December 1, 2013
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/check-anesthesia-machine
The Case
A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension,
diabetes, sleep apnea…
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psnet.ahrq.gov/node/49469/psn-pdf
December 01, 2004 - Overriding Considerations
December 1, 2004
Holtzman NA. Overriding Considerations. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/overriding-considerations
The Case
Mrs. G visited her obstetrician for first trimester routine prenatal care. The obstetrician offered genetic
testing for a variety of condition…
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psnet.ahrq.gov/node/49563/psn-pdf
May 01, 2008 - Is It Safe to Be Direct?
May 1, 2008
Kulkarni NS, Williams M. Is It Safe to Be Direct? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/it-safe-be-direct
The Case
A 92-year-old man with hypertension and heart failure (HF) was evaluated by his primary care physician
(PCP) for progressive shortness of breat…
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psnet.ahrq.gov/node/49845/psn-pdf
October 01, 2018 - Coming Up Short: Maintaining Safety in the Face of Drug
Shortages
October 1, 2018
Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
The Case
A 1-month-old preterm infant in the ne…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.362_slideshow.ppt
December 01, 2015 - PowerPoint Presentation
Spotlight
Harm From Alarm Fatigue
This presentation is based on the December 2015
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Michele M. Pelter, RN, PhD, and Barbara J. Drew, RN, PhD, University of California, San …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Wideman.pdf
April 20, 2004 - Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation
437
Barcode Medication Administration:
Lessons Learned from an Intensive
Care Unit Implementation
Mary V. Wideman, Michael E. Whittler, Timothy M. Anderson
Abstract
An electronic barcode medication administration sy…
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/implementing-automatic-referral-slides.pptx
December 31, 2022 - Building, Implementing, and Troubleshooting an Automatic Referral for Cardiac Rehabilitation
Building, Implementing & Troubleshooting an Automatic Referral for Cardiac Rehabilitation
1
This presentation is designed to help you understand the steps required for designing, testing, implementing, and troubleshootin…
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www.ahrq.gov/sites/default/files/2024-02/miller-birkmeyer-report.pdf
January 01, 2024 - Final Progress Report: Physician Organization and the Efficiency of Surgical Specialty Care
1
Title of Project
Physician Organization and the Efficiency of Surgical Specialty Care
Principal Investigator and Team Members
Dr. David C. Miller
Dr. John D. Birkmeyer
Organization
The Regents of the University of Mi…
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www.ahrq.gov/sites/default/files/2024-01/gurwitz-report.pdf
January 01, 2024 - Final Progress Report: Enhancing the Safety of Warfarin in the Nursing Home
Project Title: Enhancing the Safety of Warfarin in the Nursing Home
Principal Investigator: Jerry H. Gurwitz, MD
Principal Team Members: Jerry Gurwitz, MD; Terry S. Field, DSc; Jennifer Tjia, MD,
MSCE; Kathleen M. Mazor, EdD; Leslie R. Ha…
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www.ahrq.gov/sites/default/files/2024-02/zierler-report.pdf
January 01, 2024 - Final Progress Report: VTE Safety Toolkit: A Systems Approach to Patient Safety
Title: VTE Safety Toolkit: A Systems Approach to Patient Safety
Principal Investigator: Brenda K. Zierler, PhD1
Team Members:
Ann Wittkowsky, PharmD2
Robb Glenny, MD3
Seth Wolpin, PhD1
Jung-Ah Lee, MN1
Gene Peterson, MD, PhD3
Fre…
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www.ahrq.gov/sites/default/files/2024-01/muller-report.pdf
January 01, 2024 - Final Progress Report: Medication Reconciliation: Bridging Communications Across the Continuum of Care
Title: Medication Reconciliation: Bridging Communications Across the Continuum of
Care
Principal Investigator and Team Members: Melinda Muller, MD, Lynn Belcher, RPh,
Melissa Blanchard, MP, Amy Caster-Winegeart, …