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161. Equal Employment Opportunity and EEO Complaints Process (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policy/eeo/eeo-complaints-process-memo-signed.pdf
     April 12, 2021 - or Harassment Both supervisors and employees bear responsibility to maintain a work environment free … A Discrimination-Free AHRQ The unique attributes of each employee at AHRQ offer incalculable benefits … Therefore, I am committed to creating an environment at AHRQ that is free of barriers to full participation … Supervisors and managers bear a special responsibility to ensure that the work environment is free from

162. 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 - Am J Cardiol . 2021;140:154-156. [ Free full text ] Bõhm A, Székely A, Préda I. … JA Clin Rep . 2016;2(1):3. [ Free full text ] Liu Y, Zhang L, Wang S, et al. … Crit Care . 2016;20(1):298. [ Free full text ] Schwarz ME, Broome IJ. … J Am Coll Cardiol . 2019;73(8):964-976. [ Free full text ] Batra AS, Balaji S. … CJEM . 2023;25(4):297-298. [ Free full text ] Xing L, Wu S, Zhong X, et al.

163. Failure to adhere to dietary restrictions leading to complications and poor follow-up. | PSNet
     psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
     March 29, 2023 - There was no free air or other signs of perforation. … Front Pediatr . 2022;10:848092. [ Free full text ] Dörterler ME. … [Free full text ] Vitagliano JA, Jhe G, Milliren CE, et al. … Int J Legal Med . 2020;134(6):2121-2132. [ Free full text ] Nason KS. … [Free full text ] .  

164. Improving Allergy Documentation and Clinical Decision Support in the Electronic Health Record (EHR) - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/r01hs025375-zhou-final-report-2022.pdf
     January 01, 2022 - First, while EHRs allow structured/coded entries, reactions are frequently entered as free text, perhaps … These limitations result in half of reaction fields being left blank and one sixth being entered as free … Approximately 29 percent of reactions are entered as free text, and a third of allergy entries lack … Text Comments 123,875 (34.36%) 95,837 (35.10%) Entries with Free Text Comments Containing Uncoded … Compared with the static picklists, the pilot clinicians were less likely to enter reactions as free

165. Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
     January 01, 2023 - [Free full text] 6. Bone RC, Balk RA, Cerra FB, et al. … [Free full text] 12. Kumar A, Roberts D, Wood KE, et al. … [Free full text] 18. Shin R, Lee SM, Sohn B, et al. … [Free full text] 24. Lee DB, Shin S, Yang CS. … [Free full text] 26. Moore LJ, Moore FA.

166. “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records | PSNet
     psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
     February 01, 2023 - Am J Med . 2022;135(7):840-843. [ Free full text ] Nijor S, Rallis G, Lad N, et al. … JAMA. 2018;319(12):1276–1278. [ Free full text ] Wright A, Aaron S, Seger DL, et al. … Accessed on July 24, 2023. [ Free full text ] Bartlelt K, Joyce B, McCaffrey K, et al. … [ Free full text ] Stetson PD, Bakken S, Wrenn JO, et al. … J Am Med Inform Assoc . 2011;18(2):112-117. [ Free full text Sallam M.

167. Mosops-Amga-Flier-2022 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/MOSOPS-AMGA-flier-2022.pdf
     January 01, 2022 - SafetyCultureSurveys@westat.com  |  1-888-324-9749 DatabasesOnSafetyCulture@westat.com  |  1-888-324-9790 Free … SafetyCultureSurveys@westat.com  |  1-888-324-9749 DatabasesOnSafetyCulture@westat.com  |  1-888-324-9790 Free

168. Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
     January 01, 2023 - [Free full text] 6. Liu RT, Bettis AH, Burke TA. … [Free full text] 7. Köhne ACJ, Isvoranu AM. … [Free full text] 8. Grilo CM, Udo T. … [Free full text] 11. Ghosh T, Bol K, Butler M, et al. … [Free full text]

169. Medication Safety Events Related to Diagnostic Imaging | PSNet
     psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
     January 26, 2022 - Accessed May 4, 2022. [ Free full text ] Chung F, Abdullah HR, Liao P. … Chest . 2016;149(3):631-638. [ Free full text ] Green SM, Mason KP, Krauss BS. … [ Free full text ] American Society of Anesthesiologists. … Accessed May 5, 2022. [ Free full text ] Somogyi AA, Barratt DT, Coller JK. … [ Free full text ]  Munn Z, Jordan Z.

170. Improving Value and Efficiency in Hospitals and Medical Offices: A Resource List for Users of the AHRQ SOPS Value and Efficiency Supplemental Items (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/valueresourcelist.pdf
     January 01, 2019 - http://www.ihi.org/resources/Pages/IHIWhitePapers/Achieving-Hospital-wide-Patient- Flow.aspx (requires free … //www.ihi.org/resources/Pages/IHIWhitePapers/HospitalInpatientWasteIDToolWhitePaper .aspx (requires free … Tracker Worksheet http://www.ihi.org/resources/Pages/Tools/QISavingsTrackerWorksheet.aspx (requires free … http://www.ihi.org/resources/Pages/Tools/PatientCareExperienceObservationExercise.aspx (requires free … //www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Safe-Reliable-Effective- Care.aspx (requires free

171. Syringe Swap During Regional Block: A Case of Medication Error and Recovery. | PSNet
     psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
     November 08, 2023 - Curr Anesthesiol Rep. 2017;7:320-329. [ Free full text ] Meyer T. … [ Free full text ] Wahr JA, Abernathy JH 3rd, Lazarra EH, et al. … Br J Anaesth . 2017;118(1):32-43 . [ Free full text ] Eichhorn, JE. … Accessed January 25, 2024. [ Free full text ] Spath PL.  … BMJ . 2011;343:1-14. [ Free full text ] Green M, Tariq R, Green P.

172. Launch of SRDR Features Major Upgrades for the AHRQ-Funded Open-Access Publicly-Available Tool for Systematic Review Producers | Effective Health Care (EHC) Program
     effectivehealthcare.ahrq.gov/news/srdr-plus-launch
     This new version, called SRDR+ , is a free, powerful, online, collaborative system for extracting and … SRDR+ features major upgrades for: Researchers  as a free platform for extracting, archiving, and sharing

173. Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx (pdf file)
     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 - Free full text 11. Kroenke K, Alford DP, Argoff C, et al. … Free full text 13. … Free full text 16. Qaseem A, Wilt TJ, McLean RM, et al. … Free full text 17. Chou R, Deyo R, Friedly J, et al. … Free full text

174. Participating in the 2022 CAHPS Home and Community-Based Services Survey Database: What You Need to Know | Agency for Healthcare Research and Quality
     www.ahrq.gov/cahps/news-and-events/events/webinar-051823.html
     December 01, 2023 - May 18, 2023 Summary Speakers and Presentation Slides Recording Summary This free … Voluntary data submission opens in August to all States and is free.

175. Improving Outpatient Medication Lists Using Temporal Reasoning and Clinical Texts - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/r03hs018288-zhou-final-report-2011.pdf
     January 01, 2011 - Evaluators manually reviewed 30 free-text and 10 structured outpatient notes compared to MTERMS output … notes as these terms in free-texts have more variations. … A common occurrence in electronic order entry systems is free text medication entries. … notes as these terms in free-texts have more variations. … A common occurrence in electronic order entry systems is free text medication entries.

176. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2021-11/spotlight_integration_and_coordination_of_disesase_treatment_and_palliative_care_final.pdf
     January 01, 2021 - [Free full text] 10. Rabow M, Kvale E, Barbour L, et al. … [Free full text] 12. Harrison KL, Connor SR. … [Free full text] 13. … [Free full text] 22. Bomba PA, Morrissey MB, Leven DC. … [Free full text] 28. Kass-Bartelmes BL, Hughes R.

177. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery. | PSNet
     psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
     August 30, 2023 - Accessed March 3, 2023.[ Free full text ] Martineau M, Nelson-Piercy C. … Accessed March 3, 2023. [ Free full text ] Smiley RM, Friedman AM. … BMJ . 2013;347:f6099. [ Free full text Bates SM, Greer IA, Middeldorp S, et al. … Accessed March 3, 2023. [ Free full text ] Guglielminotti J, Li G. … Accessed March 3, 2023. [ Free full text ]. Dillon S.

178. Critical Echocardiogram Result Lost to Follow-up. | PSNet
     psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
     July 31, 2023 - OEI-06-09-00090. [ Free full text (PDF) ] de Vries EN, Ramrattan MA, Smorenburg SM, et al. … BMJ. 2019;366:l4185. [ Free full text ] Bates DW, Levine DM, Salmasian H, et al. … OEI-06-08-00220. [ Free full text (PDF) ] Transition of Care. … [Free full text ] Rennke S, Nguyen OK, Shoeb MH, et al. … PLoS One . 2018;13(2):e0191980. [ Free full text ] Kelly KJ, Doucet S, Luke A.

179. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon | PSNet
     psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
     March 29, 2023 - Front Public Health . 2022;10:818816. [ Free full text ] Sharma S, Arora L. … Accessed November 29, 2023. [ Free full text ] Bohringer C, Liu H. … J Biomed Res. 201;33(4):217–220. [ Free full text ] Murphy GS, Brull SJ. … Obes Surg . 2020;30(9):3354-3362. [ Free full text ] Pitlick MM, Volcheck GW. … Core Evid . 2013;8:57-67. [ Free full text ] Honing G, Martini CH, Bom A, et al.

180. 10 Patient Safety Tips for Hospitals (pdf file)
     www.qualitymeasures.ahrq.gov/sites/default/files/publications/files/10-tips-for-hospitals.pdf
     December 01, 2009 - Ordering information and links to free AHRQ tools are also provided. 1. … A free 10-minute patient education video and companion 24-page booklet, both in English and Spanish, … Free patient safety culture surveys for hospitals (AHRQ Publication No. 04-0041), nursing homes (AHRQ … A free 2 1⁄2-day train-the-trainer course is currently being offered in five locations nationwide. … For free copies of AHRQ tools, please call the AHRQ Publications Clearinghouse at 1-800-358-9295.