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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37000/psn-pdfSeptember 15, 2011 - Unanticipated death after discharge home from the emergency department. September 15, 2011 Sklar DP, Crandall CS, Loeliger E, et al. Unanticipated Death After Discharge Home From the Emergency Department. Ann Emerg Med. 2007;49(6). doi:10.1016/j.annemergmed.2006.11.018. https://psnet.ahrq.gov/issue/unanticipated-d… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46811/psn-pdfMay 17, 2018 - A surgical procedure grid for safety and operating room communication in multisite surgery. May 17, 2018 Insalaco LF, Spiegel JH. A Surgical Procedure Grid for Safety and Operating Room Communication in Multisite Surgery. JAMA Facial Plast Surg. 2018;20(3):185-186. doi:10.1001/jamafacial.2017.2049. https://psnet.a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836825/psn-pdfMarch 30, 2022 - Antibiotic prescribing errors in patients discharged from the pediatric emergency department. March 30, 2022 LaScala EC, Monroe AK, Hall GA, et al. Antibiotic prescribing errors in patients discharged from the pediatric emergency department. Pediatr Emerg Care. 2022;38(1):e387-e392. doi:10.1097/pec.000000000000229… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46047/psn-pdfMay 17, 2017 - Medicare failed to investigate suspicious infection cases from 96 hospitals. May 17, 2017 Jewett C. Kaiser Health News. May 9, 2017. https://psnet.ahrq.gov/issue/medicare-failed-investigate-suspicious-infection-cases-96-hospitals The Centers for Medicare and Medicaid Services decision to withhold payment for certa… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35838/psn-pdfMarch 28, 2011 - Unscheduled returns to the emergency department: an outcome of medical errors? March 28, 2011 Nuñez S, Hexdall A, Aguirre-Jaime A. Unscheduled returns to the emergency department: an outcome of medical errors? Qual Saf Health Care. 2006;15(2):102-8. https://psnet.ahrq.gov/issue/unscheduled-returns-emergency-depart… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60028/psn-pdfMarch 11, 2020 - Cracking the code for quality: the interrelationships of culture, nurse demographics, advocacy, and patient outcomes. March 11, 2020 DiCuccio MH, Colbert AM, Triolo PK, et al. Cracking the Code for Quality. J Nurs Admin. 2020;50(3):152- 158. doi:10.1097/nna.0000000000000859. https://psnet.ahrq.gov/issue/cracking-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45343/psn-pdfAugust 10, 2016 - Medication errors involving the intravenous administration route: characteristics of voluntarily reported medication errors. August 10, 2016 Wolf ZR. Medication Errors Involving the Intravenous Administration Route: Characteristics of Voluntarily Reported Medication Errors. J Infus Nurs. 2016;39(4):235-48. doi:10.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/865482/psn-pdfApril 03, 2024 - Impact of a relocation to a new critical care building on pediatric safety events. April 3, 2024 Furthmiller A, Sahay R, Zhang B, et al. Impact of a relocation to a new critical care building on pediatric safety events. J Hosp Med. 2024;19(5):589-595. doi:10.1002/jhm.13324. https://psnet.ahrq.gov/issue/impact-relo… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50749/psn-pdfDecember 18, 2019 - Medication errors in the care transition of trauma patients December 18, 2019 Martín Mª ÁP, García MM, Silveira ED, et al. Medication errors in the care transition of trauma patients. Eur J Clin Pharmacol. 2019;75(12):1739-1746. doi:10.1007/s00228-019-02757-3. https://psnet.ahrq.gov/issue/medication-errors-care-tra… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36612/psn-pdfJanuary 14, 2011 - Does the patient's payer matter in hospital patient safety?: a study of urban hospitals. January 14, 2011 Clement JP, Lindrooth R, Chukmaitov AS, et al. Does the patient's payer matter in hospital patient safety?: a study of urban hospitals. Med Care. 2007;45(2):131-8. https://psnet.ahrq.gov/issue/does-patients-pa… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47636/psn-pdfDecember 12, 2018 - Learning from tragedy: the Julia Berg story. December 12, 2018 Graber ML, Berg D, Jerde W, et al. Learning from tragedy: the Julia Berg story. Diagnosis (Berl). 2018;5(4):257-266. doi:10.1515/dx-2018-0067. https://psnet.ahrq.gov/issue/learning-tragedy-julia-berg-story This commentary provides a clinical review of … -
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/ape.htmlAugust 01, 2022 - Event Investigation and Analysis Guide: Appendix E Confirmation and Consensus Meeting Announcement Template As you may know, a patient care incident occurred on (insert date) involving (brief description of event). On behalf of (insert executive sponsor name), we are asking you to participate in our upcoming …
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/sustainability/assessment-tool.htmlMarch 01, 2017 - Sustainability Action Plan AHRQ Safety Program for Long-Term Care: HAIs/CAUTI The Sustainability Assessment Tool is developed to help you understand what project elements and other factors may influence sustainability. There are two formats to choose from. You may print the handout to write in sco…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47287/psn-pdfDecember 19, 2018 - Shifting and sharing: academic physicians' strategies for navigating underperformance and failure. December 19, 2018 LaDonna KA, Ginsburg S, Watling C. Shifting and Sharing: Academic Physicians' Strategies for Navigating Underperformance and Failure. Acad Med. 2018;93(11):1713-1718. doi:10.1097/ACM.0000000000002292… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60233/psn-pdfApril 15, 2020 - Identifying safety hazards associated with intravenous vancomycin through the analysis of patient safety event reports. April 15, 2020 Krukas A, Franklin ES, Bonk C, et al. Identifying safety hazards associated with intravenous vancomycin through the analysis of patient safety event reports. Patient Safety. 2020;2… -
www.ahrq.gov/npsd/quality-patient-safety/index.htmlAugust 01, 2020 - What is the NPSD’s Role in Quality and Patient Safety? By enabling providers, PSOs, and, eventually others to contribute nonidentifiable patient safety data to the NPSD, the stage has been set for breakthroughs in our understanding of how best to improve patient safety. The NPSD will facilitate the aggregation …
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www.ahrq.gov/hai/cusp/modules/identify/index.htmlJuly 01, 2018 - Identify Defects Through Sensemaking The Identify Defects Through Sensemaking module of the CUSP Toolkit will help you identify recurring negative events in your system and apply CUSP and Sensemaking tools to help reduce the risk of future harm to your patients. This module includes— Facilitator N…
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digital.ahrq.gov/care-setting/hospice-centerJanuary 01, 2023 - Hospice Center A Roadmap for Research: The International Summit on Innovation and Technology in Care of Older People (IS-ITCOP) Description This conference convenes interdisciplinary experts from the United States and abroad to define priorities and goals for researching techn…
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Disposition of Comments_Comparative Effectiveness Review NO. 243: Prehospital Airway Management (pdf file)
effectivehealthcare.ahrq.gov/sites/default/files/cer-243-prehospital-airway-management-disposition-comments.pdfJune 14, 2021 - It shows the most import factor is to secure an airway, with any of these three techniques that would … Further, it is extremely difficult to isolate the airway factor in the complex prehospital environment -
Ff 2009 Section4 (pdf file)
hcup-us.ahrq.gov/reports/factsandfigures/2009/pdfs/FF_2009_section4.pdfJanuary 01, 2009 - The increase in number of stays per person was a relatively more important factor in cost growth
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