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psnet.ahrq.gov/node/72616/psn-pdf
December 22, 2020 - edn5
https://psnet.ahrq.gov//#_edn7
https://psnet.ahrq.gov//#_edn5
Research Intervention Approaches
Finally
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psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
April 27, 2022 - Finally, the fragmented nature of the health care system may limit individual hospitals' incentive to
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psnet.ahrq.gov/issue/final-check-say-it-out-loud
July 31, 2023 - Multi-use Website
The Final Check: Say it Out Loud.
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August 1, 2012
This Web site provides resources to help reduce incidence of …
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psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - Finally, another gastroenterologist covering
for the patient’s primary gastroenterologist suggested … Finally, nonocclusive ischemia can result from hypovolemia, poor cardiac function, and
vasoconstrictive
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
January 01, 2022 - No
imaging was performed.
6
Case Details (3)
• Finally, another gastroenterologist covering for … – Finally, nonocclusive ischemia can result from hypovolemia, poor cardiac
function, and vasoconstrictive
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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx
Spotlight
Under Pressure: Tracheostomy Cuff Over Inflation
Leading to Tissue Necrosis and Cuff Rupture
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm…
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psnet.ahrq.gov/sites/default/files/2021-09/Battle%20Buddy%20Pocket%20Card%20-%20final%20(1).pdf
January 01, 2021 - COVID 19 Battle Buddy Support Program
Background: COVID-19 is a pandemic that threatens not only our patients but
ourselves and our sense of safety and control. Like soldiers on a battlefield, our
front line staff are coping with ongoing uncertainty about the scope of the
threat, concerns about adequate PPE, …
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psnet.ahrq.gov/primer/duty-hours-and-patient-safety
June 15, 2024 - Finally, burnout and fatigue—known risk factors for poor job performance—remain common among residents
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psnet.ahrq.gov/primer/triggers-and-trigger-tools
September 15, 2024 - Finally, most existing trigger tools have been used to identify adverse events in the inpatient setting
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psnet.ahrq.gov/perspective/conversation-elizabeth-salisbury-afshar-about-harm-reduction-strategies-improve-safety
October 30, 2024 - Finally, I have heard countless stories from my own patients about how terribly they have been treated … Finally, our team makeup is also important. … Finally, over the last few years, we've seen the federal government speak much more openly in support … Finally, research into the impact of social determinants of health, such as housing and food security
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psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-who-use-substances
October 30, 2024 - Finally, research into the impact of social determinants of health, such as housing and food security … Finally, I have heard countless stories from my own patients about how terribly they have been treated … Finally, our team makeup is also important. … Finally, over the last few years, we've seen the federal government speak much more openly in support
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psnet.ahrq.gov/node/50699/psn-pdf
November 26, 2019 - also at an increased likelihood of adverse events when not taking their medications as
prescribed.3 Finally
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psnet.ahrq.gov/node/49392/psn-pdf
April 01, 2003 - Finally, the lack of sitters could be addressed in some instances by having family members sit with a … Finally, falls are necessarily linked with mobility.
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psnet.ahrq.gov/node/49843/psn-pdf
October 01, 2018 - Finally, a 12-lead
electrocardiogram should have been performed upon the patient's arrival to the ED … Finally, clinicians have not reliably embraced these alerts.
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - Finally, educational programs to date do not stress the fundamental aim of the handoff: to create a shared … Finally, attendings can provide oversight, or review of care after it has been provided, through review
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psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
October 28, 2020 - Finally, a 12-lead electrocardiogram should have been performed upon the patient's arrival to the ED, … Finally, clinicians have not reliably embraced these alerts.
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - Finally, another gastroenterologist covering for the patient’s primary gastroenterologist suggested the … Finally, nonocclusive ischemia can result from hypovolemia, poor cardiac function, and vasoconstrictive
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psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
January 01, 2023 - residents in fall-prevention activities.
35
Systems Change Needed/Quality Improvement Approach (7)
• Finally
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psnet.ahrq.gov/node/33872/psn-pdf
January 01, 2018 - Finally, the
2018 literature provides insight into the next iteration of patient engagement research
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psnet.ahrq.gov/node/49500/psn-pdf
January 01, 2006 - Finally, preparing illustrative handouts that depict when acetaminophen is a sole
ingredient versus