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www.uspreventiveservicestaskforce.org/uspstf/document/final-evidence-summary50/impaired-visual-acuity-in-older-adults-screening-2009
July 15, 2009 - Cataract surgery was also associated with a lower risk for fracture (RR, 0.33 [CI, 0.1 to 1.0]).
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psnet.ahrq.gov/web-mm/blind-spot
July 30, 2020 - Blind Spot
Citation Text:
Lee LA. Blind Spot. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy
Citation Text:
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - SPOTLIGHT CASE
Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump
Citation Text:
Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump . PSNet [internet]. Rockville (MD): Agency for Heal…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest
Citation Text:
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. Rockvil…
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - SPOTLIGHT CASE
False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.
Citation Text:
Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-removal.pptx
April 01, 2022 - Prompting Removal of Unnecessary Indwelling Urinary Catheters
Indwelling Urinary Catheter Removal
Maintaining Catheter Awareness and Prompting Removal
AHRQ Pub. No. 17-0019-5-EF
March 2018
AHRQ Safety Program for Intensive Care Units:
Preventing CLABSI and CAUTI
AHRQ Pub. No. 17(22)-0019
April 2022
AHRQ Safety Prog…
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www.ahrq.gov/patient-safety/quality-measures/21st-century/challenges.html
June 01, 2018 - The Challenge and Potential for Assuring Quality Health Care for the 21st Century
From Quality Measures to Quality Care: Examples of Quality Improvement at Work
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Table of Contents
The Challenge and Potential for Assuring Quality Health Care for the 21st Century
From Quality …
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psnet.ahrq.gov/node/60865/psn-pdf
August 31, 2020 - In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-
BC-FACHE
August 31, 2020
In Conversation With.. Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
Editor’s Note: Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is …
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psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
October 28, 2020 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
Citation Text:
Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
October 31, 2023 - SPOTLIGHT CASE
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.
Citation Text:
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.. PSNet [internet]. Rockville (MD):…
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-appa2.pdf
January 01, 2018 - 0.028 OASIS 4 (2013-
2016)
Inpatient adverse events in adults receiving hip joint replacement due
to fracture
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psnet.ahrq.gov/web-mm/hindsight-2020-thrombolytics-alcohol-intoxication
December 18, 2024 - Cases
Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/icd-categories-prevalence-reimbursement_research.pdf
January 01, 2011 - ill-defined conditions
general symptoms (780) 90,130 201,906 891.4
800-999 Injury and poisoning fracture
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - Cases
Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture
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psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
March 27, 2024 - Cases
Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture
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digital.ahrq.gov/sites/default/files/docs/Health_IT_and_Safety_070910_comp.pdf
July 13, 2010 - 1000
• 3.19 per 1000 • 65+ = 6.5 per 1000
• 19 per 1000 (elderly) – 0.35 per 1000 (14%)
had a fracture
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psnet.ahrq.gov/node/866370/psn-pdf
July 31, 2024 - Sometimes a confused patient receives a spinal anesthetic during surgery for a hip fracture.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereport-slides.html
September 01, 2017 - 11/13/2013
COPD
Resident G
11/2/2013
Gastroenteritis
Resident G
11/11/2013
Fracture
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psnet.ahrq.gov/node/866579/psn-pdf
August 28, 2024 - Incidence and reason for readmission and
unscheduled health care contact after distal radius fracture