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Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44354/psn-pdf
    August 05, 2015 - Evaluation for occult fractures in injured children. August 5, 2015 Wood JN, French B, Song L, et al. Evaluation for Occult Fractures in Injured Children. Pediatrics. 2015;136(2):232-40. doi:10.1542/peds.2014-3977. https://psnet.ahrq.gov/issue/evaluation-occult-fractures-injured-children This study assessed an err…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41267/psn-pdf
    September 27, 2017 - Patient perceptions of missed nursing care. September 27, 2017 Kalisch BJ, McLaughlin M, Dabney BW. Patient perceptions of missed nursing care. Jt Comm J Qual Patient Saf. 2012;38(4):161-7. https://psnet.ahrq.gov/issue/patient-perceptions-missed-nursing-care Missed nursing care (failure to perform required patient…

  3. Appropriate use of cardiac stress testing with imaging: a systematic review and meta-analysis. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/health-information-technology-heart-failure-care/citation/cardiac
    January 01, 2023 - Appropriate use of cardiac stress testing with imaging: a systematic review and meta-analysis. Citation Ladapo JA, Blecker S, O'Donnell M, Jumkhawala SA, Douglas PS. Appropriate use of cardiac stress testing with imaging: a systematic review and meta-analysis. PLoS One. 2016 Aug 18;11(8):e0161153. doi…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44583/psn-pdf
    February 17, 2016 - Root Cause Analysis Playbook. February 17, 2016 Chicago, IL: American Society for Healthcare Risk Management; 2015. https://psnet.ahrq.gov/issue/root-cause-analysis-playbook Risk management has recently focused on organization-wide improvement in patient safety. This publication discusses root cause analysis metho…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39982/psn-pdf
    January 17, 2012 - Hand-off Communications. January 17, 2012 DeRosier JM, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. https://psnet.ahrq.gov/issue/hand-communications The Joint Commission Center for Transforming Hea…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43405/psn-pdf
    August 14, 2014 - Characteristics associated with postdischarge medication errors. August 14, 2014 Mixon A, Myers AP, Leak CL, et al. Characteristics associated with postdischarge medication errors. Mayo Clin Proc. 2014;89(8):1042-51. doi:10.1016/j.mayocp.2014.04.023. https://psnet.ahrq.gov/issue/characteristics-associated-postdisc…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35701/psn-pdf
    July 12, 2010 - Improving the accuracy of patient identification in the medication-use process. July 12, 2010 Trapskin PJ, White L, Armitstead JA. Improving the accuracy of patient identification in the medication-use process. Am J Health Syst Pharm. 2006;63(3):218, 220-2. https://psnet.ahrq.gov/issue/improving-accuracy-patient-i…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38513/psn-pdf
    April 01, 2009 - Commission of Inquiry on Hormone Receptor Testing. April 1, 2009 Cameron M. St. John's, NL: Government of Newfoundland and Labrador; 2009. ISBN: 978551463537.   https://psnet.ahrq.gov/issue/commission-inquiry-hormone-receptor-testing This government report investigated certain laboratory tests conducted from …

  9. Seasonal variation in readmission risk for patients hospitalized with cardiopulmonary conditions. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/health-information-technology-heart-failure-care/citation/seasonal
    January 01, 2023 - Seasonal variation in readmission risk for patients hospitalized with cardiopulmonary conditions. Citation Blecker S, Kwon JY, Herrin J, Grady JN, Horwitz LI. Seasonal variation in readmission risk for patients hospitalized with cardiopulmonary conditions. J Gen Intern Med. 2018 May;33(5):599-601. doi…

  10. Slide 1

    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/carecoordination/qdr2015-chartbook-carecoordination.pptx
    June 16, 2016 - Slide 1 National Healthcare Quality and Disparities Report Chartbook on Care Coordination June 2016 This presentation contains notes. Select View, then Notes page to read them. 1 National Healthcare Quality and Disparities Report Annual report to Congress mandated in the Healthcare Research and Quality Act of …

  11. National Healthcare Quality and Disparities Report (QDR): Care Coordination Chartbook (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/carecoordination/qdr2015-chartbook-carecoordination.pdf
    June 16, 2016 - National Healthcare Quality and Disparities Report (QDR): Care Coordination Chartbook Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov CHARTBOOK ON CARE COORDINATION National Healthcare Quality and Disparities Report This document is in the public domain and…

  12. Hold the tPA | PSNet

    psnet.ahrq.gov/web-mm/hold-tpa
    July 29, 2020 - Hold the tPA Citation Text: Fagan SC. Hold the tPA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Dow…

  13. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.344_slideshow.ppt
    April 01, 2015 - PowerPoint Presentation Spotlight Dissecting the Presentation * This presentation is based on the April 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Shirley Beng Suat Ooi, MBBS (S'pore), Emergency Medicine Department, National Univers…

  14. X-ray Flip | PSNet

    psnet.ahrq.gov/web-mm/x-ray-flip
    August 10, 2019 - X-ray Flip Citation Text: Shapiro MJ. X-ray Flip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Downl…

  15. Situational (Un)Awareness | PSNet

    psnet.ahrq.gov/web-mm/situational-unawareness
    August 01, 2009 - Situational (Un)Awareness Citation Text: Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…

  16. Did We Forget Something? | PSNet

    psnet.ahrq.gov/web-mm/did-we-forget-something
    April 28, 2021 - Did We Forget Something? Citation Text: Gibbs VC. Did We Forget Something?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…

  17. Primers | PSNet

    psnet.ahrq.gov/primers-0
    March 15, 2025 - Primers Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts. Latest Primers Clinical Decision Support Systems March…

  18. Timely diagnosis of esophageal perforation | PSNet

    psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
    September 27, 2023 - Timely diagnosis of esophageal perforation Citation Text: Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX …

  19. Slide 1

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/leveraging-cultural-change-080814.pptx
    January 01, 2013 - Slide 1 Leveraging Cultural Change to Reduce Urinary Catheter Use 1 Linda Greene, RN,MPS,CIC Manager Infection Prevention Highland Hospital Jennifer Tuttle, RN, MSNEd Adult Critical Care Unit Tucson Medical Center Learning Objectives Describe the way in which improvement in the clinical culture can facilitate e…

  20. Impact of prior clinical information in an EHR on care outcomes of emergency patients. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/community-shared-clinical-abstract-improve-care/citation/impact
    January 01, 2023 - Impact of prior clinical information in an EHR on care outcomes of emergency patients. Citation Theera-Ampornpunt N, Speedie SM, Du J, et al. Impact of prior clinical information in an EHR on care outcomes of emergency patients. AMIA Annu Symp Proc 2009 Nov 14;2009:634-8. PMID: 20351932. Link …
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