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  1. 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…
  2. 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…
  3. 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…
  4. 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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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 …
  8. 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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. 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 …
  15. 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…
  16. 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…
  17. 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…
  18. 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…
  19. 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…
  20. 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, …