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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving-facnotes.docx
May 01, 2017 - Further, understanding how a team is structured and how multiple teams interact in a center is critical … a problem, because the surgeon or physician invites team members to do so. … They can facilitate a discussion of how to solve problems so they do not reoccur. … to train everyone how to use it before they try it with a patient. … ASK: How do we change this?
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.pdf
August 01, 2010 - Case Study on Nurse Bedside Shift Report: Advocate Trinity Hospital, Anne Arundel Medical
Center, … For more
information, see the case
study at the end of this
handbook. … :: 14
Case Study
on Nurse Bedside Shift Report:
Advocate Trinity Hospital, Anne
Arundel Medical … This case study highlights key elements of the experiences at
each hospital. … Chaboyer W, McMurray A, Wallis M. Bedside nursing handover: a case study.
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psnet.ahrq.gov/issue/validation-hospital-administrative-dataset-adverse-event-screening
May 21, 2009 - May 17, 2023
Do patients' disruptive behaviours influence the accuracy of a doctor's … A randomised experiment. … February 14, 2024
How would final-year medical students perform if their skill-based … January 18, 2013
Challenges and opportunities to prevent transfusion errors: a Qualitative … cross-sectional case study of puncture/laceration.
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs023708-senathirajah-final-report-2021.pdf
January 01, 2021 - Once a patient display is created, it can be shared with other users who do
not need to locate the information … To do this study, users completed five tasks and were interviewed about their information needs. … stop it at this point in order to do preliminary data analysis. … human would do, automating the navigation and extraction, albeit in a non-native manner. … of
how to bring researchers and vendors closer to work together.
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www.ahrq.gov/sites/default/files/2025-04/elder-report.pdf
January 01, 2025 - Case study by office site: Each site was initially analyzed as an independent case study. … Qualitative analysis and case study by site: As described above for aim 2, all the data
sources above … Comparative case analysis: Each office case study was used as data in a comparative case
analysis looking … (how much do you like it?) … The tension between needing to improve
care and knowing how to do it.
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psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - For each medication, a team member should ask how often and when the patient takes it. … For example, ask how the patient checks their blood sugars instead of “ do you check your blood sugars … It may be helpful to inquire how the patient addresses hypoglycemic episodes to understand their need … If a patient is suspected to be on sliding scale insulin, it is important to clarify and document how … There are many resources available to train staff from varied disciplines on how to perform a BPMH.
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psnet.ahrq.gov/node/49836/psn-pdf
July 01, 2018 - circumvent a problem to achieve a goal,
or do so more easily. … In the case study, the use of a Foley catheter to maintain the patency of a stoma in
the absence of … For example,
the case study described using a Foley catheter to maintain patency of a stoma in the absence … In the case study, the radiology staff did not question the disappearance of the
catheter. … To Do No Harm: Ensuring Patient Safety in Health Care Organizations. Jossey-
Bass; 2005.
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/prosthesis_research-protocol.pdf
March 16, 2017 - In adults who use a lower limb prosthesis, how do the relative effects on
ambulatory, functional, and … How do these percentages vary based on the following characteristics? … • Any study design
• No minimum sample size (except not case reports)
• No minimum followup time … an analysis
• No minimum sample size (other than no case reports)
• No minimum followup time … sample size (other than no case reports)
• No minimum followup time
KQ 7
Population
• As per
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hcup-us.ahrq.gov/datainnovations/clinicaldata/MNPOAvideotranscript.pdf
September 24, 2010 - studies. … In the
first case study, a patient with no prior history of heart disease is admitted after
developing … Next slide on screen: Case Study #1 – POA Coding
Michael speaking:
Final diagnosis codes list … Michael on screen:
In the second case study, a patient is admitted for a diagnostic work‐up of … Michael on screen:
Michael speaking:
11
In the third case study, a diabetic patient
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.152_slideshow.ppt
June 01, 2007 - Class Mortality
I—A normal healthy patient 0%
II—A patient with mild systemic disease 0.2%
III—A … threat to life 15.2%
V—A moribund patient who is not expected to survive without the operation 70% … How Could This Error Have Been Prevented? … History
More careful history with open-ended question
“Do you have any other symptoms or concerns … cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11818784
How Could This Error Have Been Prevented
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integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan/establish-protocols-identify-patients-who-could-benefit-integrated-care
February 01, 2025 - How Do You Do It? … How will the involvement of a behavioral health provider be proposed? … (PDSA) Worksheet
What Not To Do
Don’t rely … Integrated Team Shared Responsibility for Behavioral Health
This case … study focuses on the mental health integration (MHI) model at Intermountain Healthcare.
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psnet.ahrq.gov/node/61083/psn-pdf
October 28, 2020 - Do you
want to start talking about how the COVID-19 response and the work of the Initiative have intersected … The concept
of social distancing is pretty foreign to staff and many don’t know how to safely have a … do that job in a pandemic. … How do you separate people from each other if one becomes ill and the other does not? … You can
have huge teleconference calls where people can hear case studies, hear the expertise, and ask
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psnet.ahrq.gov/issue/twelve-tips-engaging-learners-checking-health-care-decisions
February 27, 2014 - Related Resources From the Same Author(s)
Finding and fixing mistakes: do … April 17, 2013
Do you have to re-examine to reconsider your diagnosis? … March 18, 2013
Comparative effectiveness of a serious game and an e-module to support … April 10, 2019
Comfort with uncertainty: reframing our conceptions of how clinicians … addressing disruptive physician behavior: a composite case study.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-module_2-speaker-notes.docx
September 01, 2015 - In this module, we will use a case scenario to examine ways to prevent CAUTI when a catheter is already … Well, how we handle the catheter tubing and bag can make a big difference.” … Nurse: “Another thing we can do to help prevent a CAUTI from developing is to find a safe place to hang … Ramirez, I can show you how I apply a securement device on the tubing and secure it to her leg. … The nurse places the securement device on the patient’s leg, making sure to show the transporter how
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.72_slideshow.ppt
September 01, 2004 - cognitive steps to determine prognosis in elderly patients
Case: Poor Prognosis
A 91-year-old woman … A CT scan revealed a thyroid mass. … A repeat FNA was performed. … “How long do I have to live?” … the patient had stated previously that she did not want to be intubated for a long period.
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effectivehealthcare.ahrq.gov/sites/default/files/arcia-presentation.pdf
May 29, 2025 - I am going to do that in
the form of two case studies, the first talking about
tailored visualization … You
really do need
to give people information
in
a way that they can
find
usable … So tell
us
what you
think we're trying to say. How do you
interpret this information? … But the process of the focus groups did help us to do a preliminary
comprehension check based on how … 24
The second case study is one that I'm originating.
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/asthma-nonpharmacologic-treatment_research-protocol.pdf
October 04, 2016 - Case reports that describe adverse events associated with bronchial thermoplasty will
be considered … Case series and case reports will be considered for inclusion if they
describe adverse events associated … Below, we discuss the primary domains and how they will be
considered as inputs to the ratings:
Risk … Case study of the comparison of data from
conference abstracts and full-text articles in health technology … Technical Experts do not do analysis of
any kind nor do they contribute to writing the report.
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psnet.ahrq.gov/node/49411/psn-pdf
July 01, 2003 - a health care proxy or completed a living will prior to admission. … appreciate how effective it is likely to be in their situation. … Teach residents how to elicit patients’ preferences and arrive at goals of care.(8) Physicians rarely … Opening the black box: how do physicians communicate
about advance directives. … How do medical residents discuss resuscitation with patients?
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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 01, 2011 - Clinicians may appreciate that error disclosure is "the right thing to do" but experience insurmountable … Determining exactly how an error happened and formulating a plan for preventing recurrences can be especially … Do house officers learn from their mistakes? JAMA. 1991;265:2089-94.[ go to PubMed ]
10. … Why do people sue doctors? A study of patients and relatives taking legal action. … June 21, 2013
How surgeons disclose medical errors to patients: a study using standardized
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psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
January 01, 2016 - How strategic were you in the beginning? Did you say we need to do this, this, and this? … How can we do a better job getting our patients access to care? … How can we do a better job making sure all the lab tests reach the right people who need to know? … We could start in medical school to ask students, how well do you think you're going to do on this test … You get so much more information from watching how a clinician analyzes a case than you do from how they