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psnet.ahrq.gov/issue/wrong-patient-blood-transfusion-error-leveraging-technology-overcome-human-error
December 09, 2020 - Study
Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration.
Citation Text:
Hensley NB, Koch CG, Pronovost P, et al. Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Int…
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psnet.ahrq.gov/issue/automated-identification-antibiotic-overdoses-and-adverse-drug-events-analysis-prescribing
May 08, 2017 - September 30, 2010
Potentially harmful medication dispenses after a fall or hip fracture
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psnet.ahrq.gov/issue/associations-between-patient-factors-and-adverse-events-home-care-setting-secondary-data
November 27, 2013 - November 17, 2015
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/issue/identification-serious-and-reportable-events-home-care-delphi-survey-develop-consensus
November 27, 2013 - requiring emergency treatment, catheter-associated infections, and incidents related to care that did not fall
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psnet.ahrq.gov/issue/frequency-and-characteristics-errors-artificial-intelligence-ai-reading-screening-mammography
February 03, 2016 - April 19, 2023
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/issue/identifying-and-quantifying-medication-errors-evaluation-rapidly-discontinued-medication
February 03, 2011 - Study
Identifying and quantifying medication errors: evaluation of rapidly discontinued medication orders submitted to a computerized physician order entry system.
Citation Text:
Koppel R, Leonard CE, Localio R, et al. Identifying and quantifying medication errors: evaluation of rapidl…
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psnet.ahrq.gov/issue/using-computerized-provider-order-entry-and-clinical-decision-support-improve-referring
August 20, 2018 - November 16, 2022
A randomized trial of a multifactorial strategy to prevent serious fall
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www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
December 01, 2017 - Infection rates from hospital epidemiology and infection prevention also present known complications. … The patient is not assessed for fall risk, and no preventive measures are taken.
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/delirium-1.pdf
March 01, 2020 - Delirium in elderly adults: Diagnosis, prevention and treatment. … Delirium in elderly adults: Diagnosis, prevention and
treatment. … Nonpharmacological interventions aimed at prevention or
reduction of delirium fall into several domains … The fall
rates in 2011 and 2012 were 3.01
and 2.82 falls per 1,000 patient
days and in 2013 decreased … The
resulting Prevention of Delirium
Programme combines a
multicomponent delirium
prevention and
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
December 01, 2017 - Infection rates from hospital epidemiology and infection prevention also present known complications. … The patient is not assessed for fall risk, and no preventive measures are taken.
5.
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digital.ahrq.gov/ahrq-funded-projects/improving-patient-safetyquality-health-information-technology-implementation
January 01, 2023 - Joseph's also targeted specific adverse events for prevention through better design. … satisfaction, length of stay and cost per discharge, as well as on each of the adverse events targeted for prevention
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www.ahrq.gov/patient-safety/quality-measures/21st-century/challenges.html
June 01, 2018 - Among these are:
The Prevention of Heart Attacks with Beta-Blocker Treatment
Despite the clear medical … They plan to publish data on angioplasty and coronary artery bypass surgery in the fall of 1998 ( The … In 1989, the National Institutes of Health initiated the National Asthma Education and Prevention Program … Under a 4-year program, the Centers for Disease Control and Prevention (CDC) and the Health Care Financing … HCFA is working with its Peer Review Organizations (PROs), the Centers for Disease Control and Prevention
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hcup-us.ahrq.gov/datainnovations/clinicaldata/ExampleofUsingPOA-CMSHACsusingall-payerdata.jsp
August 01, 2011 - An Example of Using Present on Admission Data: CMS-Defined Hospital-Acquired Conditions in All-Payer Data
An official website of the Department of Health & Human Services
Search All AHRQ Websites
…
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T2-Antibiotic_Pocket_Cards.pdf
May 01, 2014 - Advancing Excellence in Health Care www.ahrq.gov
Agency for Healthcare Research and Quality
Nursing Home Infection Control
Guidelines for C. Difficile
When to Perform Toxin Assay on Stool:
• Resident symptomatic with diarrhea ( >3 loose/watery
stools a day).
• Especially consider in residents who received…
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psnet.ahrq.gov/issue/swarming-improve-patient-care-novel-approach-root-cause-analysis
September 23, 2020 - March 24, 2019
Potentially harmful medication dispenses after a fall or hip fracture:
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www.ahrq.gov/news/newsletters/e-newsletter/918.html
June 01, 2024 - AHRQ Commits to Priority Actions for Suicide Prevention . Upcoming AHRQ Webinars . … AHRQ Commits to Priority Actions for Suicide Prevention The Biden-Harris administration's 2024 National … Strategy for Suicide Prevention introduced a comprehensive,10-year plan to tackle suicide across society
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/build-businesscase-slides.pptx
January 01, 2017 - Estimating the attributable mortality of ventilator-associated pneumonia from randomized prevention studies … mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomized prevention … Estimating the attributable mortality of ventilator-associated pneumonia from randomized prevention studies … mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomized prevention
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/booklets/gallbladder-booklet.pdf
November 01, 2023 - If your blood pressure is low, we may have you wait
so you don’t faint or fall. … Call, Don’t Fall!
Do NOT get up on your own the first time! … You may be lightheaded and could fall.
Press the call button. And a nurse will help you
get up. … Recovery in the Hospital
Moving Helps You Recover
Call, Don’t Fall!
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effectivehealthcare.ahrq.gov/sites/default/files/interventions-horizon-scan-high-impact-1306.pdf
June 01, 2013 - -
prevention design such as nonskid floor surfaces, extra handrails, more aisle lighting, and
bedside … blood pressure, labs, medication
compliance), treatment (wound care, medication reconciliation), prevention … (immunizations, fall
assessment), and referral (medical and social services). … prevention measures such as
nonskid floor surfaces, handrails, aisle lighting, and bedside commodes … Eagle (CO): Western Eagle County Health
Services District; 2011 Fall. 48 p.
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psnet.ahrq.gov/issue/corridor-care-emergency-department-managing-patient-care-non-clinical-areas-safely-and
May 19, 2021 - Journal Article
Study
Catching those who fall