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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-0122-technical-specs.pdf
June 02, 2025 - High-Risk Deliveries at Facilities with 24/7 In-House Blood Banking/Transfusion Services - Technical Specifications
Section II: Detailed Measure Specifications
A. Description
Reporting on the extent to which high risk women are delivered at facilities
with 24/7 on-site blood banking ser…
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psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
March 01, 2015 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay
Citation Text:
O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
G…
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psnet.ahrq.gov/node/49793/psn-pdf
May 01, 2017 - https://psnet.ahrq.gov/web-mm/hemolysis-holdup
The Case
A 72-year-old man with congestive heart failure
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.326_slideshow.ppt
June 01, 2014 - allowed to leave their unit
3
Case: Wandering Off the Floors
A 74-year-old man with a history of congestive … heart failure (CHF) secondary to alcoholic dilated cardiomyopathy was admitted for management of alcohol
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/xUc_vXf7323faUQY7SePhT
January 01, 2002 - increase the future risk for
a more disabling condition, such as recurrent
myocardial infarction or congestive … heart failure, and
may lead to premature death.
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psnet.ahrq.gov/node/49501/psn-pdf
February 03, 2006 - Lost in Transition
February 1, 2006
Beach C. Lost in Transition. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/lost-transition
Case Objectives
Provide an overview of transitions in continuously operating industries
Review cognitive error
Describe the complex dynamics of transitions in emergency care
Pro…
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psnet.ahrq.gov/node/866205/psn-pdf
July 10, 2024 - Hemorrhagic Shock after Elective Spine Surgery: Failure
to Rescue after Limited Response to Nursing Concerns.
July 10, 2024
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response
to Nursing Concerns. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/hemorrhagic-sh…
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hcup-us.ahrq.gov/toolssoftware/ccs/AppendixCMultiDX.txt
April 18, 2016 - ] -
42741 42742 4275
7.2.11 Congestive … heart failure; nonhypertensive [108 … 42821 42822 42823 42830 42831 42832 42833 42840 42841
42842 42843
7.2.11.1 Congestive … heart failure -
4280 … 7.2.11.2 Heart failure -
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hcup-us.ahrq.gov/datainnovations/clinicaldata/AppendixEAHRQProjectDetails.jsp
October 05, 2010 - 426.2 - 426.6), pleural effusion (511.1, 511.8, 511.9), decubitus ulcer (707.0), skin edema (782.3), congestive … heart failure (428 series), lower respiratory inflammation (490, 491 series, 494), chronic lung disease … developed for five medical Inpatient Quality Indicators (IQI; acute myocardial infarction [IQI 15], congestive … heart failure [IQI 16], acute stroke [IQI 17], gastrointestinal hemorrhage [IQI 18], and pneumonia [
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-250-cannabis-2024-surv-rep-update-table-e5.xlsx
January 01, 2024 - not initiating cannabis NR 156 (3 years, 2018-2021) Long NR Ischemic heart disease, hypertension, heart … failure, chronic obstructive pulmonary disease, diabetes mellitus, educational level, and numeric age … as underlying pain diagnosis, and history of cardiometabolic disease (e.g., hypertension, diabetes, heart … failure) NR NR NR NR NR NR A vs. … failure: 13/5,309 vs. 119/26,531, RR 0.63 (95% CI 0.26 to 0.99) NR Foundation Moderate
33933061 Lee
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.344_slideshow.ppt
April 01, 2015 - PowerPoint Presentation
Spotlight
Dissecting the Presentation
*
This presentation is based on the April 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Shirley Beng Suat Ooi, MBBS (S'pore), Emergency Medicine Department, National Univers…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/tool_safe-mgso4.docx
May 30, 2013 - AHRQ Safety Program for Perinatal Care: Safe Medication Administration: Magnesium Sulfate
AHRQ Safety Program for Perinatal Care
Safe Medication Administration
Magnesium Sulfate
Safe Medication Administration—Magnesium Sulfate
Purpose of the tool: This tool describes the key perinatal safety elements with examples for…
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psnet.ahrq.gov/print/pdf/node/845971
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Value and Patient Safety
Curated Library
Foundations
Safety is the preservation of value.
Vandeskog B. J Safety Res. 2024;89:105-115.
Safety is at the heart of safety science, and yet “safety” lacks a consensus definition among safety
resea…
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www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary/aspirin-use-prevent-cardiovascular-disease-colorectal-cancer-preventive-medication-2002
January 15, 2002 - increase the future risk for a more disabling condition, such as recurrent myocardial infarction or congestive … heart failure, and may lead to premature death.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.pdf
April 01, 2011 - readmissions rates for Medicare patient who had been treated for at least
one of three conditions (heart … failure, heart attack, or pneumonia) within the last 30
days. … Failure. … failure or high blood
pressure, and steps toward
discharge in plain language. … Transitional care of older adults
hospitalized with heart failure: a randomized, controlled trial.
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hcup-us.ahrq.gov/db/nation/neds/stats/NEDS_2019_IP_MaskedStats.PDF
January 01, 2019 - & SUBACUTE ENDOCARDITIS W CC 598 0.01
290: ACUTE & SUBACUTE ENDOCARDITIS W/O CC/MCC 75 0.00
291: HEART … FAILURE & SHOCK W MCC 43,477 0.92
291: HEART FAILURE & SHOCK W MCC OR PERIPHERAL EXTRACORPOREAL MEMBRANE … OX
125,772 2.65
292: HEART FAILURE & SHOCK W CC 38,235 0.81
293: HEART FAILURE & SHOCK W/O CC/MCC … FAILURE & SHOCK W MCC 43,486 0.92
291: HEART FAILURE & SHOCK W MCC OR PERIPHERAL EXTRACORPOREAL MEMBRANE … OX
125,803 2.65
292: HEART FAILURE & SHOCK W CC 38,245 0.81
293: HEART FAILURE & SHOCK W/O CC/MCC
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www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-mar2023.pdf
July 14, 2023 - Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare
Federal Interagency Workgroup:
Improving Diagnostic Safety and Quality in Healthcare
March Meeting Summary
Workgroup Goal: Established in response to Senate Report 115-150. The Senate Committee on
Appropriations requested “AHRQ t…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/atrial-fibrillation_disposition-comments.pdf
June 28, 2013 - failure symptoms
o Control of AF symptoms (e.g., palpitations,
exercise capacity)
o Quality of life … failure and coexisting atrial
fibrillation (Healy et al). … failure with
respect to exercise tolerance. … failure, and LVEF.”) should head the list. … failure or
other associated risk factors.
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - Retained Surgical Items: Causation and Prevention
Citation Text:
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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Format:
Google Scholar BibTeX End…
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psnet.ahrq.gov/node/33562/psn-pdf
September 15, 2024 - Rapid Response Systems
September 15, 2024
Rapid Response Systems. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/rapid-response-systems
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field.…