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4981. EMS Patient Safety in the Field | PSNet
      psnet.ahrq.gov/perspective/ems-patient-safety-field
      July 28, 2021 - to the right hospital. … You are there to interact with the hospitals in the area, particularly during emergency events, to make … your community and with your hospitals. … issue shortly after it occurred, or when something is falling out of their usual case management. … In some cities with hospitals that have developed that level of sophistication, they now put CT scans

4982. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication | PSNet
      psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
      August 01, 2012 - Around 10 days after hospital discharge, the patient was seen by the neurosurgeon, who now recommended … Most hospitals utilize some form of peer review to identify care process and system solutions that can … An online survey of 339 institutions including 61 teaching hospitals confirmed that most facilities have … Falling through the cracks: information breakdowns in critical care handoff communication. … Opportunities to improve clinical summaries for patients at hospital discharge.

4983. Can Research Help Us Improve the Medical Liability System? | PSNet
      psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
      March 01, 2012 - The error is intercepted by the hospital pharmacist before the medication is scheduled to be administered … Allen Kachalia, MD, JD Associate Chief Quality OfficerBrigham & Women's Hospital References   … Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. … How does the brand new risk manager at a 150-bed community hospital in Ypsilanti get this work done? … July 8, 2020 Inpatient Notes: mistakes in the hospital—communicating, apologizing, and

4984. In Conversation With… Richard C. Boothman, JD | PSNet
      psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
      March 01, 2012 - How does the brand new risk manager at a 150-bed community hospital in Ypsilanti get this work done? … The error is intercepted by the hospital pharmacist before the medication is scheduled to be administered … Allen Kachalia, MD, JD Associate Chief Quality OfficerBrigham & Women's Hospital References   … Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. … September 21, 2005 View More See More About The Topic Hospitals Health

4985. Learning from Primary Care Meaningful Use Exemplars - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r18hs022701-ornstein-final-report-2014.pdf
      January 01, 2014 - 71 practices on 21 CQM in the 2014 MU CQM set and a web-based survey of 319 providers in … For example, participants noted that there is not clear data to support the CQM Screening for falls … in the elderly. … In addition, the physicians participating in the focus groups had years of experience using EHR in their … Prevention of falls in community-dwelling older adults: U.S.

4986. CAUTI Sustainability: Embedding CAUTI Policies, Using Data to Monitor Proress and Hardwiring CUSP Principles | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/cauti-sustainability-slides.html
      December 01, 2017 - We don’t all address a problem in the same way, and  there are variations in our processes. … Am J Health Promot (in press). … Slide 40 Successful Hospitals Examples Using validated resources: AHA/IHI collaboratives … Mentality: CEO to Environmental services to patients and families Slide 41 Successful Hospitals … It’s one of 28 hospitals in the U.S.. and the first in Tennessee.

4987. Industrial and Systems Engineering and Health Care: Critical Areas of Research Workshop - Research Agenda for Healthcare Systems Engineering (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/Research%20Agenda%20for%20Healthcare%20Systems%20Engineering.pdf
      February 13, 2007 - Aging of both the patient population and the large generation of hospitals built in the Hill-Burton … era of the 1950’s and 1960’s has produced a boom in hospital and other clinic construction. … Besides hospitals and physicians working alone or in small partnerships, there are ambulatory clinics … For example, monitoring patients in their homes may reduce the need for return visits to hospitals. … Zayas-Castro Process Design/Reengineering in Hospital Environments Professor and Chairperson Department

4988. State Documentation of Racial and Ethnic Health Disparities to Inform Strategic Action
      hcup-us.ahrq.gov/reports/race/R_E_Disparities_rpt.jsp
      July 01, 2016 - Other types of data that states use vary based on what the states and hospitals record and, therefore … populations by county, centers for primary care by legislative district, and acute care hospitals by … CLAS Happen: Six Areas for Action . 57 Massachusetts also instituted a policy that requires all hospitals … hospital discharge data. … The state enacted legislation in 2009 that requires hospitals to report self-reported race/ethnicity

4989. Recommendation: Cognitive Impairment in Older Adults: Screening | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/recommendation/cognitive-impairment-in-older-adults-screening
      February 25, 2020 - with harms, some of which are serious, including central nervous system disturbances, bradycardia, and falls … Overall, there was no increase in serious adverse events in patients taking AChEIs. … individual studies reported increased rates of serious adverse events, such as bradycardia, syncope, falls … A comparison of the prevalence of dementia in the United States in 2000 and 2012. … associated with adverse effects, which overall are small but occasionally serious, including syncope or falls

4990. Final Progress Report: Leveraging a Social Network of Elders and Families To Improve Medication Safety at Transitions of Care (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/quintana-report.pdf
      January 01, 2024 - Participants in the living laboratory have care from doctors and hospitals in eastern Massachusetts, … Adverse reactions as a cause of hospital admission in the aged. Drugs Aging. 1992;2(4):356-367. … Evaluation of Adverse Drug Events and Medication Discrepancies in Transitions of Care Between Hospital … Clinical computing in a teaching hospital. N Engl J Med. 1985;312(12):756-764. PMID: 3838364 51. … CDC http://www.cdc.gov/ncipc/factsheets/fallcost.htm; CDCReport: A Toolkit to Prevent Senior Falls https

4991. Procalcitonin Executive (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/procalcitonin_executive.pdf
      October 01, 2012 - is more specific for bacterial infections, with serum levels rising at the onset of infection and falling … Settings: ICUs (medical and surgical), inpatient acute care hospitals, emergency departments, and outpatient … A meta-analysis was performed on short-term mortality (28-day or in-hospital mortality) in a group … Both studies were limited to the acute-care hospital setting. … There is disagreement, however, over whether this range falls within the appropriate noninferiority

4992. Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
      January 01, 2023 - • A few hours later, the clinic surgeon further reviewed the prior hospital record and noted the … are under-read because the primary inquiry was satisfied. 25 PEG Tube Complications (4) • Most hospitals … to enhance radiologists’ performance. – An online survey of 339 institutions including 61 teaching hospitals … Falling through the cracks: information breakdowns in critical care handoff communication. … Opportunities to improve clinical summaries for patients at hospital discharge.

4993. The Deadly Duo | PSNet
      psnet.ahrq.gov/web-mm/deadly-duo
      April 28, 2021 - May 5, 2014 The effects of hospital-physician financial integration on adverse incident … the Children's Hospitals' Solutions for Patient Safety Collaborative. … March 20, 2019 Resource-based view on safety culture's influence on hospital performance … : a study of U.S. hospitals. … October 27, 2021 Speaking up about patient safety in psychiatric hospitals - a cross-sectional

4994. Developing an Effective Care Coordination System Implementation Guide
      www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/care-coordination-slides.pptx
      January 01, 2018 - original training modules are one hour-long training sessions originally presented live to a group of hospitals … sessions held between 2020–2022, featuring discussions among CR experts and CR champions from diverse hospitals … The 2011 study demonstrated that implementing AR and effective CC are quality improvement steps that hospitals … 31 Possible Solutions: Transportation Hospital-sponsored bus passes Family and caregivers Hybrid versions … INTERESTED IN CR? DATE INTEREST ASSESSED CHARGED/ RECEIVED HOSPITAL BILL?

4995. Meeting Minutes, July 2021 | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/events/nac/2021-07-nac/nacmtg071421-minutes.html
      December 01, 2021 - R.N., FAAN, FACMI, Columbia University Asaf Bitton, M.D., M.P.H., Ariadne Labs, Brigham and Women’s Hospital … Dahlen, M.H.S.A., FACHE, Consumer Health Ratings Susan Edgman-Levitan, P.A., Massachusetts General Hospital … Safety-net hospitals under mandatory bundled payment (to examine the impact of the Centers for Medicare … Brady also emphasized AHRQ’s programs for reducing hospital (or healthcare)-acquired infections (HAIs … Concerning the switch to ambulatory care, a surgery patient can stay overnight in a hospital and not

4996. Evidence-based Practice Center Systematic Review Protocol (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/recombinant-factor-viia_disposition-comments.pdf
      June 01, 2010 - supporting off-label drug use falls short of the rigor that accompanies FDA review. … There is no indication that the sample of hospital oversamples hospitals that are high-end users of … and in the non-hospital setting. … rFVIIa in US hospitals." … This could be interpreted in a number of ways: best hospitals, largest hospitals etc.

4997. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. | PSNet
      psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
      July 08, 2022 - A study in King’s College Hospital found 31% of patients were determined to lack mental capacity, and … similar studies in general hospitals have found 9-52% of patients lacked mental capacity. 1  Thus, it … There is a major gap in access to palliative care outside the hospital, and it is not uncommon for these … & Palliative Medicine Department of Internal Medicine, Division of Hospital Medicine UC Davis Health … October 1, 2008 View More See More About The Topic Residents Hospitals

4998. Department of Veterans Affairs Emergency Airway Management Initiative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Stalhandske_71.pdf
      February 23, 2008 - in VA hospitals. … Availability of personnel in the hospital 24 hours a day, 7 days a week. 2. … around the clock in fewer than 30 percent of VHA hospitals. … many VHA hospitals. … In one hospital, two internal medicine chief residents live on the hospital grounds for a year and provide

4999. Care Transitions and Teamwork in Pediatric Trauma: Implications for HIT Design - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r01hs023837-gurses-final-report-2021.pdf
      January 01, 2021 - which the patient receives care while in the hospital. … while they are in the hospital. … A Level 1 trauma center in a 87-bed academic children’s hospital in Midwest. … A level 1 pediatric trauma center in an academic hospital in Midwest. Participants. … A level 1 pediatric trauma center in an academic hospital located in Midwest. Participants.

5000. S108 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/s108.pdf
      October 01, 2007 - During the hospital stay, individuals in state 1 were eligible to transition to state 2 but not vice … The reason for this difference was that individuals who remained in the hospital had longer period of … This framework avoids pit- falls associated with intermediate variables. … in 3 hospitals in Argentina: a prospective, matched analysis. … A Methodologically Focused Review of the Literature in Hospital Epidemiology and Infec- tion Control