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Showing results for "failures".

4841. Medication discrepancy rates and sources upon nursing home intake: a prospective study. | PSNet
      psnet.ahrq.gov/issue/medication-discrepancy-rates-and-sources-upon-nursing-home-intake-prospective-study
      February 12, 2020 - Study Medication discrepancy rates and sources upon nursing home intake: a prospective study. Citation Text: Patterson ME, Bollinger S, Coleman C, et al. Medication discrepancy rates and sources upon nursing home intake: a prospective study. Res Social Adm Pharm. 2022;18(5):2830-2836. do…

4842. Factors contributing to an increase in duplicate medication order errors after CPOE implementation. | PSNet
      psnet.ahrq.gov/issue/factors-contributing-increase-duplicate-medication-order-errors-after-cpoe-implementation
      December 31, 2014 - Study Factors contributing to an increase in duplicate medication order errors after CPOE implementation. Citation Text: Wetterneck TB, Walker JM, Blosky MA, et al. Factors contributing to an increase in duplicate medication order errors after CPOE implementation. J Am Med Inform Assoc. …

4843. Unexpected death within 72 hours of emergency department visit: were those deaths preventable? | PSNet
      psnet.ahrq.gov/issue/unexpected-death-within-72-hours-emergency-department-visit-were-those-deaths-preventable
      July 08, 2020 - Study Unexpected death within 72 hours of emergency department visit: were those deaths preventable? Citation Text: Goulet H, Guerand V, Bloom B, et al. Unexpected death within 72 hours of emergency department visit: were those deaths preventable? Crit Care. 2015;19(1):154. doi:10.1186/s…

4844. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/transfer.html
      September 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Electronic Reports Transfer Risk Report Table 1. Sample High-Risk Transfer Report Facility Name: Unit: Report Date: Resident Name and Advance Directive Status # ED Visits Within: ED Discharg…

4845. Electronic health records, communication, and data sharing: challenges and opportunities for improving the diagnostic process. | PSNet
      psnet.ahrq.gov/issue/electronic-health-records-communication-and-data-sharing-challenges-and-opportunities
      October 13, 2018 - Study Electronic health records, communication, and data sharing: challenges and opportunities for improving the diagnostic process. Citation Text: Quinn M, Forman J, Harrod M, et al. Electronic health records, communication, and data sharing: challenges and opportunities for improving t…

4846. Effects of two commercial electronic prescribing systems on prescribing error rates in hospital in-patients: a before and after study. | PSNet
      psnet.ahrq.gov/issue/effects-two-commercial-electronic-prescribing-systems-prescribing-error-rates-hospital
      September 01, 2016 - Study Effects of two commercial electronic prescribing systems on prescribing error rates in hospital in-patients: a before and after study. Citation Text: Westbrook JI, Reckmann MH, Li L, et al. Effects of two commercial electronic prescribing systems on prescribing error rates in hos…

4847. Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire. | PSNet
      psnet.ahrq.gov/issue/uncovering-system-errors-using-rapid-response-team-cross-coverage-caught-crossfire
      April 24, 2018 - Study Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire. Citation Text: Kaplan LJ, Maerz LL, Schuster KM, et al. Uncovering System Errors Using a Rapid Response Team: Cross-Coverage Caught in the Crossfire. The Journal of Trauma: Injury, Infect…

4848. Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study. | PSNet
      psnet.ahrq.gov/issue/identifying-avoidable-harm-family-practice-randucla-appropriateness-method-consensus-study
      December 16, 2020 - Study Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study. Citation Text: Carson-Stevens A, Campbell S, Bell BG, et al. Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study. BMC Fam Pract. 2019…

4849. Overcoming COVID-19: what can human factors and ergonomics offer? | PSNet
      psnet.ahrq.gov/issue/overcoming-covid-19-what-can-human-factors-and-ergonomics-offer
      September 02, 2020 - Commentary Emerging Classic Overcoming COVID-19: what can human factors and ergonomics offer? Citation Text: Gurses AP, Tschudy MM, McGrath-Morrow S, et al. Overcoming COVID-19: what can human factors and ergonomics offer? J Patient Saf Risk Manag. 2020;25(2):49…

4850. The analysis of hospital readmission rates after the implementation of Hospital Readmissions Reduction Program. | PSNet
      psnet.ahrq.gov/issue/analysis-hospital-readmission-rates-after-implementation-hospital-readmissions-reduction
      October 12, 2022 - Study The analysis of hospital readmission rates after the implementation of Hospital Readmissions Reduction Program. Citation Text: Muchiri S, Azadeh-Fard N, Pakdil F. The analysis of hospital readmission rates after the implementation of hospital readmissions reduction program. J Patie…

4851. Mortality due to hospital-acquired infection after cardiac surgery. | PSNet
      psnet.ahrq.gov/issue/mortality-due-hospital-acquired-infection-after-cardiac-surgery
      February 12, 2020 - Study Mortality due to hospital-acquired infection after cardiac surgery. Citation Text: Massart N, Mansour A, Ross JT, et al. Mortality due to hospital-acquired infection after cardiac surgery. J Thorac Cardiovasc Surg. 2022;163(6):2131-2140.e3. doi:10.1016/j.jtcvs.2020.08.094. Copy C…

4852. Better nurse staffing is associated with survival for Black patients and diminishes racial disparities in survival after in-hospital cardiac arrests. | PSNet
      psnet.ahrq.gov/issue/better-nurse-staffing-associated-survival-black-patients-and-diminishes-racial-disparities
      June 02, 2021 - Study Better nurse staffing is associated with survival for Black patients and diminishes racial disparities in survival after in-hospital cardiac arrests. Citation Text: Brooks Carthon M, Brom H, McHugh MD, et al. Better nurse staffing is associated with survival for black patients and …

4853. Did duty hour reform lead to better outcomes among the highest risk patients? | PSNet
      psnet.ahrq.gov/issue/did-duty-hour-reform-lead-better-outcomes-among-highest-risk-patients
      January 13, 2010 - Study Did duty hour reform lead to better outcomes among the highest risk patients? Citation Text: Volpp KG, Rosen AK, Rosenbaum PR, et al. Did duty hour reform lead to better outcomes among the highest risk patients? J Gen Intern Med. 2009;24(10):1149-55. doi:10.1007/s11606-009-1011-z…

4854. Using IT to Improve the Quality of Cardiovascular Disease (CVD) Prevention & Management - 2010 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/using-it-improve-quality-cardiovascular-disease-cvd-prevention-and-management/annual-summary/2010
      January 01, 2010 - Using IT to Improve the Quality of Cardiovascular Disease (CVD) Prevention & Management - 2010 Project Name Using IT to Improve the Quality of Cardiovascular Disease (CVD) Prevention and Management Principal Investigator Williams, Andrew Organization Kaiser Foundation Researc…

4855. Stroke hospitalization after misdiagnosis of "benign dizziness" is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods. | PSNet
      psnet.ahrq.gov/issue/stroke-hospitalization-after-misdiagnosis-benign-dizziness-lower-specialty-care-general
      May 12, 2021 - Study Stroke hospitalization after misdiagnosis of "benign dizziness" is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods. Citation Text: Chang T-P, Bery AK, Wang Z, et al. Stroke hospitalization after misdiagnosis of …

4856. Improving Quality through Decision Support for Evidence-Based Pharmacotherapy - 2011 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/improving-quality-through-decision-support-evidence-based-pharmacotherapy/annual-summary/2011
      January 01, 2011 - Improving Quality through Decision Support for Evidence-Based Pharmacotherapy - 2011 Project Name Improving Quality through Decision Support for Evidence-Based Pharmacotherapy Principal Investigator Lobach, David Organization Duke University Funding Mechanism RFA: H…

4857. Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme. | PSNet
      psnet.ahrq.gov/issue/medical-team-training-and-coaching-veterans-health-administration-assessment-and-impact-first
      December 21, 2014 - Study Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme. Citation Text: Neily J, Mills PD, Lee P, et al. Medical team training and coaching in the Veterans Health Administration; assessment and im…

4858. Adverse events in intensive care and continuing care units during bed-bath procedures: the prospective observational NURSIng during critical carE (NURSIE) study. | PSNet
      psnet.ahrq.gov/issue/adverse-events-intensive-care-and-continuing-care-units-during-bed-bath-procedures
      March 05, 2025 - Study Adverse events in intensive care and continuing care units during bed-bath procedures: the prospective observational NURSIng during critical carE (NURSIE) study. Citation Text: Decormeille G, Maurer-Maouchi V, Mercier G, et al. Adverse events in intensive care and continuing care u…

4859. Association between hospital performance on patient safety and 30-day mortality and unplanned readmission for Medicare fee-for-service patients with acute myocardial infarction. | PSNet
      psnet.ahrq.gov/issue/association-between-hospital-performance-patient-safety-and-30-day-mortality-and-unplanned
      June 22, 2022 - Study Association between hospital performance on patient safety and 30-day mortality and unplanned readmission for Medicare fee-for-service patients with acute myocardial infarction. Citation Text: Wang Y, Eldridge N, Metersky ML, et al. Association Between Hospital Performance on Patie…

4860. Analyzing diagnostic errors in the acute setting: a process-driven approach. | PSNet
      psnet.ahrq.gov/issue/analyzing-diagnostic-errors-acute-setting-process-driven-approach
      December 07, 2022 - Study Analyzing diagnostic errors in the acute setting: a process-driven approach. Citation Text: Griffin JA, Carr K, Bersani K, et al. Analyzing diagnostic errors in the acute setting: a process-driven approach. Diagnosis (Berl). 2022;9(1):77-88. doi:10.1515/dx-2021-0033. Copy Citatio…