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Showing results for "failures".

  1. Table A: Indicator Rates for the HCBS and Full Medicaid Populations (Rates of Admission per 100,000 Persons) | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/oirtab.html
    December 01, 2012 - Assessing the Health and Welfare of the HCBS Population Table A: Indicator Rates for the HCBS and Full Medicaid Populations (Rates of Admission per 100,000 Persons) Previous Page Next Page Table of Contents Assessing the Health and Welfare of the HCBS Population Introduction HCBS Population Av…

  2. 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/ereports.html
    September 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Electronic Reports Five reports are described here. Each section presents a sample report followed by purpose, description, and users and potential uses. The reports are: Transfer Risk Reports  (A high r…

  3. Coaching (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_6-coaching-speaker-notes.pdf
    July 01, 2023 - Coaching Hospital AIM Team Leads SPPC‐II Coaching Module 6 of 8 SPPC‐II Toolkit SCRIPT Welcome to Module 6 of the SPPC‐II Teamwork Toolkit. In this module, we’ll learn some tactics for coaching your frontline providers on using the teamwork tools. 1 Hospital AIM Team Leads SPPC‐II Coaching …

  4. Coaching (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_6-coaching-speaker-notes.pdf
    July 01, 2023 - Coaching Hospital AIM Team Leads SPPC‐II Coaching Module 6 of 8 SPPC‐II Toolkit SCRIPT Welcome to Module 6 of the SPPC‐II Teamwork Toolkit. In this module, we’ll learn some tactics for coaching your frontline providers on using the teamwork tools. 1 Hospital AIM Team Leads SPPC‐II Coaching …

  5. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures | PSNet

    psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
    November 27, 2019 - Such efforts empower trauma teams to understand their previous failures, learn from previous successes

  6. "Do You Want Everything Done?": Clarifying Code Status | PSNet

    psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
    March 27, 2024 - SPOTLIGHT CASE "Do You Want Everything Done?": Clarifying Code Status Citation Text: Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. …

  7. Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx Spotlight Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts  Source and Credits • This presentation is based on the January 2023 AHRQ WebM&M Spotl…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867850/psn-pdf
    February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/persp…

  9. Statistical Brief #21

    hcup-us.ahrq.gov/reports/statbriefs/sb21.jsp
    December 21, 2006 - Statistical Brief #21 An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs Email Updates …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867520/psn-pdf
    January 15, 2025 - Characteristics and trends of medical diagnostic errors in the United States. January 15, 2025 Ao HS, Matthews T. Characteristics and trends of medical diagnostic errors in the United States. Patient Safety. 2024;6(1):123603. doi:10.33940/001c.123603. https://psnet.ahrq.gov/issue/characteristics-and-trends-medical…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45989/psn-pdf
    June 07, 2017 - Radiologic safety events within a pediatric emergency medicine network. June 7, 2017 Blumberg SM, Mahajan P, O?Connell KJ, et al. Radiologic Safety Events Within a Pediatric Emergency Medicine Network. Pediatr Emerg Care. 2017;33(2):92-96. doi:10.1097/PEC.0000000000000684. https://psnet.ahrq.gov/issue/radiologic-s…

  12. MHA/AHRQ Clinically Enhanced Data Project (pdf file)

    hcup-us.ahrq.gov/datainnovations/clinicalcontentenhancementtoolkit/mn19.pdf
    June 21, 2014 - MHA/AHRQ Clinically Enhanced Data Project ENROLL NOW! Your Hospital gains Comparative Analysis Compare your risk-adjusted outcomes to other hospitals Improve pharmacological management of patients with Acute Decompensated Heart Failure (ADHF) Framework for other priority initiatives such as: p…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37309/psn-pdf
    January 05, 2012 - Adverse drug events in hospitalized cardiac patients. January 5, 2012 Fanikos J, Cina J, Baroletti S, et al. Adverse drug events in hospitalized cardiac patients. Am J Cardiol. 2007;100(9):1465-9. https://psnet.ahrq.gov/issue/adverse-drug-events-hospitalized-cardiac-patients This study noted two adverse drug event…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43847/psn-pdf
    January 28, 2015 - Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. January 28, 2015 Salazar MJB, Minkoff H, Bayya J, et al. Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. J Am Coll Surg. 2014;219(5):1001-7. doi:10.1016/j.jamcollsurg.201…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73343/psn-pdf
    June 02, 2021 - Hospital surveys by the Centers for Medicare and Medicaid Services: an analysis of more than 34,000 deficiencies. June 2, 2021 Antognini JF. Hospital surveys by the Centers for Medicare and Medicaid Services: an analysis of more than 34,000 deficiencies. J Patient Saf. 2021;17(4):e274-e279. doi:10.1097/pts.0000000…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46629/psn-pdf
    November 22, 2017 - A piece of my mind. Despite my best intentions. November 22, 2017 Kahn JS. Despite My Best Intentions. JAMA. 2017;318(17). doi:10.1001/jama.2017.6123. https://psnet.ahrq.gov/issue/piece-my-mind-despite-my-best-intentions End-of-life care can be difficult for patients, families, and the care team. This commentary of…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44634/psn-pdf
    November 21, 2016 - The Family Caregiver Activation in Transitions (FCAT) tool: a new measure of family caregiver self-efficacy. November 21, 2016 Coleman EA, Ground KL, Maul A. The Family Caregiver Activation in Transitions (FCAT) Tool: A New Measure of Family Caregiver Self-Efficacy. Jt Comm J Qual Patient Saf. 2015;41(11):502-7. h…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73372/psn-pdf
    June 09, 2021 - Impact of COVID-19 on inpatient clinical emergencies: a single-center experience. June 9, 2021 Mitchell OJL, Neefe S, Ginestra JC, et al. Impact of COVID-19 on inpatient clinical emergencies: a single- center experience. Resusc Plus. 2021;6:100135. doi:10.1016/j.resplu.2021.100135. https://psnet.ahrq.gov/issue/imp…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47439/psn-pdf
    January 17, 2019 - Prevalence of and factors associated with patient nondisclosure of medically relevant information to clinicians. January 17, 2019 Levy AG, Scherer AM, Zikmund-Fisher BJ, et al. Prevalence of and Factors Associated With Patient Nondisclosure of Medically Relevant Information to Clinicians. JAMA Netw Open. 2018;1(7)…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851359/psn-pdf
    July 12, 2023 - Evidence for anchoring bias during physician decision- making. July 12, 2023 Ly DP, Shekelle PG, Song Z. Evidence for anchoring bias during physician decision-making. JAMA Intern Med. 2023;183(8):818-823. doi:10.1001/jamainternmed.2023.2366. https://psnet.ahrq.gov/issue/evidence-anchoring-bias-during-physician-dec…
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