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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - Rescue Improvement Conference Innovation Summary
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July 23, 2024
View more articles from the same authors.
Innovation
Contact
…
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psnet.ahrq.gov/node/49572/psn-pdf
October 01, 2008 - Mistaken Identity
October 1, 2008
Hall LW. Mistaken Identity. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/mistaken-identity
The Case
An 85-year-old Cantonese-speaking woman was admitted to the medical service with altered mental status
and a reported fall. After finding tenderness in her left hip, the p…
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www.ahrq.gov/news/newsroom/ahrq-stats.html
July 01, 2025 - Toolkit Significantly Reduces Hospital Falls A safety toolkit funded by AHRQ helped hospitals reduce … patient falls overall by 15 percent and falls resulting in injuries by 34 percent, according to a study … Medicare Payments for Falls Medicare was the most common expected payer in 2017 for emergency department … treatment of injuries due to falls (38 percent). … Declining In-Hospital Hip Fractures The average hospital rate of in-hospital hip fractures due to falls
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www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary/healthful-diet-and-physical-activity-for-cardiovascular-disease-prevention-in-adults-without-known-risk-factors-behavioral-counseling-july-2017
July 11, 2017 - There was no evidence of greater incidence of serious adverse events, injuries, or falls in intervention … Seven physical activity–focused trials (n = 3565) reported the incidence of injuries, fractures, or falls … with known cardiovascular risk factors or to prevent or manage other health risks and conditions (eg, falls … Seven PA trials generally found no differences in rates of injuries, fractures, falls, or CV events. … Only 1 trial among women aged 40-74 y found significantly more injuries and falls among intervention
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effectivehealthcare.ahrq.gov/sites/default/files/crosscutting-horizon-scan-high-impact-1406.pdf
June 01, 2014 - designed to
interrupt propofol infusion if the patient’s oxygen saturation level or respiration rate falls … If the onus
of improving patient adherence falls on the provider, staffing needs might increase due … The ED’s physical layout may pose a risk of falls for elderly patients, narrow and thin
mattresses … at Mount Sinai Hospital (New York, NY), reported that “up to eight elderly
patients a month were falling … experts
thought these costs would be offset by reduced readmissions, reduced adverse events (e.g., falls
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…
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psnet.ahrq.gov/node/49525/psn-pdf
December 01, 2006 - Hidden Heparins: HIT Happens
December 1, 2006
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
Case Objectives
Review the presentation of heparin-induced thrombocytopenia (HIT) and its primary complication,
thrombosis.
Discuss the managem…
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - August 9, 2023
Cost of inpatient falls and cost-benefit analysis of implementation of
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/booklets/laparotomy-patient.pdf
November 01, 2023 - Recovering After Emergency Laparotomy
Recovering After
Emergency Laparotomy
e
Emergency Laparotomy Patient Education Guide 1
Recovering After Emergency
Laparotomy
Patient Name ___________________________________________________________________
Surgeon Name ________________________________________________…
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www.ahrq.gov/sites/default/files/2024-01/anumba-report_0.pdf
January 01, 2024 - Traumatic are problems such as slips trips or falls.
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cds.ahrq.gov/sites/default/files/workgroups/226/mar-2017-cholesterol-wg-notes.docx
January 01, 2017 - Title of document or resource
Repository Work Group
Meeting Summary
Date
03/08/2017
Time
1:30 – 3:30 PM ET
AGENDA
· Clarify Details Related to Existing Artifacts
· Logic exclusions, specification of conditions, lookback periods and the inclusion of parameters for scalar values
· Considerations for art…
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psnet.ahrq.gov/issue/clinical-characteristics-and-short-term-outcomes-acute-kidney-injury-missed-diagnosis-older
April 20, 2022 - Study
Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit.
Citation Text:
Li Q, Hu P, Kang H, et al. Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis…
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digital.ahrq.gov/ahrq-funded-projects/computer-assisted-medication-and-patient-information-interface-campii/annual-summary/2011
January 01, 2011 - Computer Assisted Medication and Patient Information Interface (CAMPII) - 2011
Project Name
Computer Assisted Medication and Patient Information Interface (CAMPII)
Principal Investigator
Ziemer, David C.
Organization
Emory University
Funding Mechanism
RFA: HS08-269:…
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psnet.ahrq.gov/issue/evaluation-policies-limiting-opioid-exposure-opioid-prescribing-and-patient-pain-opioid-naive
May 18, 2022 - Study
Evaluation of policies limiting opioid exposure on opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large American health system.
Citation Text:
Rennert L, Howard KA, Walker KB, et al. Evaluation of policies limiting opioid exposure on o…
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psnet.ahrq.gov/issue/safe-practice-recommendations-use-copy-forward-nursing-flow-sheets-hospital-settings
May 18, 2022 - Study
Safe practice recommendations for the use of copy-forward with nursing flow sheets in hospital settings.
Citation Text:
Patterson ES, Sillars DM, Staggers N, et al. Safe Practice Recommendations for the Use of Copy-Forward with Nursing Flow Sheets in Hospital Settings. Jt Comm J Qu…
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psnet.ahrq.gov/issue/development-and-applications-veterans-health-administrations-stratification-tool-opioid-risk
April 01, 2020 - Study
Development and applications of the Veterans Health Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide.
Citation Text:
Oliva EM, Bowe T, Tavakoli S, et al. Development and applications of the Veterans He…
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psnet.ahrq.gov/issue/effect-standardized-handoff-curriculum-improved-clinician-preparedness-intensive-care-unit
October 19, 2022 - Study
Classic
Effect of standardized handoff curriculum on improved clinician preparedness in the intensive care unit: a stepped-wedge cluster randomized clinical trial.
Citation Text:
Parent B, LaGrone LN, Albirair MT, et al. Effect of Standardized Handoff Curr…
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psnet.ahrq.gov/issue/long-term-outcomes-medication-intervention-using-screening-tool-older-persons-potentially
July 31, 2024 - Study
Long-term outcomes of medication intervention using the screening tool of older persons potentially inappropriate prescriptions screening tool to alert doctors to right treatment criteria.
Citation Text:
Frankenthal D, Israeli A, Caraco Y, et al. Long-Term Outcomes of Medication In…
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www.ahrq.gov/news/newsroom/case-studies/202105.html
November 01, 2021 - Primary Care Providers in Pennsylvania Use Medication for Successful Treatment of Opioid Use Disorders
Search All Impact Case Studies
November 2021
The Lehigh Valley Health Network (LVHN) used an AHRQ initiative to expand treatment for opioid use disorders in Pennsylvania. As a result, primary care physic…
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psnet.ahrq.gov/issue/perceptions-pediatric-hospital-safety-culture-united-states-analysis-2016-hospital-survey
January 19, 2022 - Study
Perceptions of pediatric hospital safety culture in the United States: an analysis of the 2016 Hospital Survey on Patient Safety Culture.
Citation Text:
Gampetro PJ, Segvich JP, Jordan N, et al. Perceptions of Pediatric Hospital Safety Culture in the United States: An Analysis of t…