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Showing results for "failures".

6521. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
      August 01, 2022 - This case revealed numerous system failures that contributed to the initial misdiagnosis and needless … Communication failures: an insidious contributor to medi- cal mishaps.

6522. Misplaced Nasogastric Tube Resulting in Aspiration | PSNet
      psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
      August 01, 2009 - There is evidence that communication and handoff failures are a root cause of two-thirds of sentinel

6523. Final Progress Report: Consumer-Led Workshop To Advance Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/peck-report.pdf
      January 01, 2024 - which the invisible wall that typically separates consumers and providers when we discuss healthcare failures … reports  searchable information tied to medical nomenclature thesaurus  stories of both solutions and failures … national patient safety policies or guidelines, collect and analyze reports of medical errors or system failures

6524. Icd-Categories-Prevalence-Reimbursement Research (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/icd-categories-prevalence-reimbursement_research.pdf
      January 01, 2011 - Prevalence and Medicare reimbursement by recurrent International Classification of Diseases categories, 2006-2009 Utilization and Costs Data Points #5 In 2009, Medicare reimbursement for inpatient claims totaled $126.7 billion, more than 25 percent of which was for circula- tory diseases. The total per claim r…

6525. Evidence-based Practice Center Systematic Review Protocol (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/type-2-diabetes-medications-update_research-protocol.pdf
      April 06, 2010 - Evidence-based Practice Center Systematic Review Protocol Source: www.effectivehealthcare.ahrq.gov Published Online: April 06, 2010 1 Evidence-based Practice Center Systematic Review Protocol Project Title: Comparative Effectiveness and Safety of Oral Diabetes Medications for Adu…

6526. Statistical Brief #94: Adult Hospital Stays with Infections Due to Medical Care, 2007 (pdf file)
      hcup-us.ahrq.gov/reports/statbriefs/sb94.pdf
      November 01, 2008 - Statistical Brief #94: Adult Hospital Stays with Infections Due to Medical Care, 2007 From HEALTHCARE COST AND UTILIZATION PROJECT Agency for Healthcare Research and Quality STATISTICAL BRIEF #94 August 2010 Highlights ■ Infections due to medical care were associated with significantly hi…

6527. doi:10.1016/S0749-3797(03)00122-3 (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/hWzpnYXDpQzUr8U_5xY6qS
      January 01, 2003 - doi:10.1016/S0749-3797(03)00122-3 Screening for High Blood Pressure Recommendations and Rationale U.S. Preventive Services Task Force Introduction This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommenda- tions on screening for high blood pressure in adults and the supporting evidence,…

6528. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
      January 01, 2021 - Spotlight Spotlight An Inadvertent Bolus of Norepinephrine Source and Credits • This presentation is based on the May 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Sarina Fazio, PhD, RN, Emma Blackmon, PhD, RN, Amy Doroy, PhD,…

6529. Emergency Department Visits for Adults with Diabetes, 2010 - Statistical Brief #167
      hcup-us.ahrq.gov/reports/statbriefs/sb167.jsp
      November 01, 2013 - Emergency Department Visits for Adults with Diabetes, 2010 - Statistical Brief #167 An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact …

6530. Final Progress Report: MOVES: Patient-Based Strategy To Reduce Errors in Diabetes Care (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/oconnor-report.pdf
      January 01, 2024 - Final Progress Report: MOVES: Patient-Based Strategy To Reduce Errors in Diabetes Care O’Connor, Patrick J. Final Report MOVES: Patient-Based Strategy to Reduce Errors in Diabetes Care Patrick J. O’Connor MD MPH, Principal Investigator Research Team Members: JoAnn Sperl-Hillen MD, Paul E. Johnson PhD†, William A. …

6531. Section 7: Measuring Value in a Care Management Program | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm7.html
      October 01, 2014 - strategy is important, because by doing so a State can identify both short- and long-term successes and failures

6532. Improving Care Transitions for Complex Patients through Decision Support - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017795-eisenstein-final-report-2012.pdf
      January 01, 2012 - Improving Care Transitions for Complex Patients through Decision Support - Final Report Grant Final Report Grant ID: R18HS017795 Improving Care Transitions for Complex Patients through Decision Support Inclusive Project Dates: 09/30/08 – 09/29/12 Principal Investigator: Eric L. Eisenstein, DBA (…

6533. Primary Care Interventions to Prevent Child Maltreatment: Evidence Report and Systematic Review for the US Preventive Services Task Force (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/XGHwLrLfb_78ymEUwGF6jR
      March 19, 2024 - Primary Care Interventions to Prevent Child Maltreatment: Evidence Report and Systematic Review for the US Preventive Services Task Force Primary Care Interventions to Prevent Child Maltreatment Evidence Report and Systematic Review for the US Preventive Services Task Force Meera Viswanathan, PhD; Caroline Rains, MPH…

6534. Comparative Effectiveness of Pain Management Interventions fo Hip Fracture (ppt file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/hip-fracture-pain.ppt
      May 01, 2011 - Comparative Effectiveness of Pain Management Interventions fo Hip Fracture Pain Management Interventions for Hip Fracture Prepared for: Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov Pain Management Interventions for Hip Fracture This slide set is based on a comparative effectiveness review (CER) ti…

6535. Comparative Effectiveness of Pain Management Interventions fo Hip Fracture (ppt file)
      effectivehealthcare.ahrq.gov/sites/default/files/hip-fracture-pain.ppt
      May 01, 2011 - Comparative Effectiveness of Pain Management Interventions fo Hip Fracture Pain Management Interventions for Hip Fracture Prepared for: Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov Pain Management Interventions for Hip Fracture This slide set is based on a comparative effectiveness review (CER) ti…

6536. 09-0071-Ef 1 (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/09-0071-EF_1.pdf
      June 01, 2009 - data theft, accidental disclosure of patient information, data errors and omissions, and technology failures … This coverage is concerned with performance failures and negligence with respect to products and services

6537. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60268/psn-pdf
      April 29, 2020 - Complications of ECMO During Transport April 29, 2020 Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport The Case A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with acute on chro…

6538. Two-Day Training Content | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/team/teach/two-day.html
      February 01, 2024 - Two-Day Training Content The Team Leadership Module provides an overview of what teams are as well as how to lead teams effectively. The overview of teams can be taught in about 40 minutes using the approach described  The Team Leadership Module provides an overview of what teams are as well as how to lead te…

6539. A Fatal Twist in Pseudohyperkalemia | PSNet
      psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
      February 10, 2021 - SPOTLIGHT CASE A Fatal Twist in Pseudohyperkalemia Citation Text: Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: …

6540. Statistical Brief #72: Nationwide Frequency and Costs of Potentially Preventable Hospitalizations, 2006 (pdf file)
      hcup-us.ahrq.gov/reports/statbriefs/sb72.pdf
      April 01, 2009 - Statistical Brief #72: Nationwide Frequency and Costs of Potentially Preventable Hospitalizations, 2006 HEALTHCARE COST AND UTILIZATION PROJECT Agency for Healthcare Research and Quality STATISTICAL BRIEF #72 April 2009 Highlights In 2006, hospital costs for potentially preventable cond…