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4561. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet
      psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
      March 25, 2020 - SPOTLIGHT CASE Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Citation Text: Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…

4562. Final Progress Report: The National Quality Forum National Annual Policy Conference 2007 (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/feeney-report.pdf
      January 01, 2025 - CMS defines value-based purchasing broadly, including a focus on prevention, pay for reporting, pay … The study found that 87 percent of the surveyed hospitals did not follow guidelines for infection prevention … The training regimen focused on communication, resource management, error prevention, and site-specific … NQF- endorsement TM is expected in fall 2008. … Funder: Centers for Disease Control and Prevention Endorsing a Framework for Multi-Faceted Physician

4563. Too Many Cooks in the Kitchen | PSNet
      psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
      March 07, 2018 - admitted to a major trauma center for a pathologic pelvic fracture (secondary to osteoporosis) after a fall … Pressure Ulcer Prevention in the Hospital Setting Using Silicone Foam Dressings. 

4564. Enhancing Complex Care through an Integrated Care Coordination Information System - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017832-dorr-final-report-2012.pdf
      January 01, 2012 - These included 3 specific for older adult prevention (cognitive screening at 75, falls screening at

4565. AHRQ's Evidence-based Practice Center Division Annual Report 2021: Solving the Puzzle for Evidence-Based Decision Making (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pdf/epc-year-in-review-2021.pdf
      January 01, 2021 - The program continued to address COVID-19 prevention and treatment, as well as pain management, women … Osteoporosis Prevention, Screening, and Diagnosis https://bit.ly/373w7LX Long-Term Drug Therapy and … Nutrition as Prevention for Improved Cancer Outcomes. … Nutrition as Prevention for Improved Cancer Outcomes https://go.usa.gov/xuxyz 11. … Office of Disease Prevention (ODP) 14.

4566. EQUIP (Enhancing Quality in Patient Care Utilizing Information Technology in Patient Care) (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015354-rachman-final-report-2007.pdf
      January 01, 2007 - Furthermore, many EHRS implementations that phase in functionality “stall” and fall short of significant

4567. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840174/psn-pdf
      August 28, 2024 - and a thoracic aortic aneurysm presented to the Emergency Department (ED) after a syncopal event and fall

4568. Module 6: Sustainability: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module6/mod6-facguide.html
      March 01, 2017 - Module 6: Sustainability: Facilitator Notes AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Slide 1: Module 6: Sustainability Say: The Sustainability module of this toolkit helps an organization maintain and sustain a process that has worked well. Slide 2: Objectives Say: In this module we wi…

4569. Missed CANDOR Implementation Opportunities. | PSNet
      psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
      November 11, 2020 - and a thoracic aortic aneurysm presented to the Emergency Department (ED) after a syncopal event and fall

4570. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head | PSNet
      psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
      March 27, 2024 - dangerous mechanism (i.e., pedestrian struck by motor vehicle, occupant ejected from motor vehicle, or fall … negative CT interpretation would result in a treatment plan that does not include measures aimed at prevention

4571. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73128/psn-pdf
      July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients. April 7, 2021 https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications- and-enhances Summary The Hospital at Homesm program provides hospital-level care…

4572. Implement Teamwork and Communication for Perinatal Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.pdf
      May 01, 2017 - Implement Teamwork and Communication for Perinatal Safety AHRQ Safety Program for Perinatal Care Implement Teamwork and Communication for Perinatal Safety AHRQ Publication No. 17-0003-3-EF May 2017 SAY: The Implement Teamwork and Communication module of the AHRQ Safety Program for Perinatal Care will help yo…

4573. In Conversation With… Kaveh Shojania, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
      February 26, 2025 - In Conversation With… Kaveh Shojania, MD November 1, 2015  Citation Text: In Conversation With… Kaveh Shojania, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation For…

4574. Classics and Emerging Classics | PSNet
      psnet.ahrq.gov/classics
      August 01, 2023 - Classics and Emerging Classics To help our readers navigate the tremendous breadth of the PSNet Collection, AHRQ PSNet editors and advisors have given the designation of “Classic” to review articles, empirical studies, government and stakeholder reports, commentaries, and books of lasting importance to the patient sa…

4575. Do Not Disturb! | PSNet
      psnet.ahrq.gov/web-mm/do-not-disturb
      February 03, 2011 - SPOTLIGHT CASE Do Not Disturb! Citation Text: Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

4576. Hypoxemia after Emergency Intubation | PSNet
      psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
      March 24, 2019 - tube (ETT) placement was confirmed by auscultation of breath sounds and observation of chest rise and fall

4577. Archived: Screening: Evidence Summary: Gestational Diabetes Mellitus, Screening | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/document/-screening-evidence-summary/gestational-diabetes-mellitus-screening-january-2014
      May 15, 2013 - A diagnosis of GDM is made when 1 or more glucose values fall at or above the specified thresholds. … [PMID: 17180809] Hill JC, Krishnaveni GV, Annamma I, Leary SD, Fall CH.

4578. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49844/psn-pdf
      October 01, 2018 - Diffusion of Responsibility Leads to Danger October 1, 2018 Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger The Case A 70-year-old man was sent to the emergency department (ED) from a nursing facility…

4579. Wrong Route for Nutrients | PSNet
      psnet.ahrq.gov/web-mm/wrong-route-nutrients
      September 04, 2010 - Air October 1, 2004 WebM&M Cases Another Fall

4580. Understanding Quality Measurement | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/understand/index.html
      June 01, 2020 - When rates fall outside of normally observed ranges or well below established goals, investigation may