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Showing results for "incidents".

  1. 2021 National Healthcare Quality and Disparities Report: Executive Summary (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr-final-es.pdf
    January 01, 2021 - 2021 National Healthcare Quality and Disparities Report: Executive Summary …

  2. Low on the Totem Pole | PSNet

    psnet.ahrq.gov/web-mm/low-totem-pole
    October 01, 2003 - SPOTLIGHT CASE Low on the Totem Pole Citation Text: Wachter R. Low on the Totem Pole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

  3. The Inside of a Time Out | PSNet

    psnet.ahrq.gov/web-mm/inside-time-out
    March 01, 2004 - The Inside of a Time Out Citation Text: Feldman DL. The Inside of a Time Out. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …

  4. Medication Reconciliation Technology to Improve Quality of Transitional Care - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/publication/r18hs018183-weiner-final-report-2013.pdf
    January 01, 2013 - Medication Reconciliation Technology to Improve Quality of Transitional Care - Final Report Grant Final Report Grant ID: R18HS018183 Medication Reconciliation Technology to Improve Quality of Transitional Care Inclusive Project Dates: 09/30/09 – 07/31/13 Principal Investigator: Michael Weiner Team Member…

  5. Statewide Implementation of Electronic Health Records | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/statewide-implementation-electronic-health-records
    January 01, 2023 - Statewide Implementation of Electronic Health Records Project Final Report ( PDF , 67.36 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. …

  6. Double Trouble | PSNet

    psnet.ahrq.gov/web-mm/double-trouble
    August 01, 2012 - SPOTLIGHT CASE Double Trouble Citation Text: Gurwitz JH. Double Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

  7. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. | PSNet

    psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
    January 29, 2021 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. Citation Text: Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…

  8. Crossing the Line | PSNet

    psnet.ahrq.gov/web-mm/crossing-line
    December 01, 2012 - SPOTLIGHT CASE Crossing the Line Citation Text: Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…

  9. Health IT Hazard Manager Beta-Test (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/HealthITHazardManagerFinalReport.pdf
    May 01, 2012 - The Patient Safety Act focuses on learning from retrospective analysis of safety incidents and adverse … It broadens an otherwise limited focus on safety incidents (and their most salient root causes) to a … Fear of medico-legal exposure has long prevented the sharing of information about medical safety incidents … (The EHRevent incident reporting system focuses on incidents where patients are harmed, rather than … An analysis of computer-related patient safety incidents to inform the development of a classification

  10. Evidence Summary: Ovarian Cancer: Screening | United States Preventive Services Taskforce

    www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary/ovarian-cancer-screening
    February 13, 2018 - Share to Facebook Share to X Share to WhatsApp Share to Email Print Evidence Summary Ovarian Cancer: Screening February 13, 2018 Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an offi…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47603/psn-pdf
    March 20, 2019 - Electronic patient identification for sample labeling reduces wrong blood in tube errors. March 20, 2019 Kaufman RM, Dinh A, Cohn CS, et al. Electronic patient identification for sample labeling reduces wrong blood in tube errors. Transfusion (Paris). 2019;59(3):972-980. doi:10.1111/trf.15102. https://psnet.ahrq.g…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867379/psn-pdf
    January 01, 2025 - Implementation of electronic triggers to identify diagnostic errors in emergency departments. December 18, 2024 Vaghani V, Gupta A, Mir U, et al. Implementation of electronic triggers to identify diagnostic errors in emergency departments. JAMA Intern Med. 2025;185(2):143-151. doi:10.1001/jamainternmed.2024.6214. …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48095/psn-pdf
    June 26, 2019 - Exposure to incivility hinders clinical performance in a simulated operative crisis. June 26, 2019 Katz D, Blasius K, Isaak R, et al. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ Qual Saf. 2019;28(9):750-757. doi:10.1136/bmjqs-2019-009598. https://psnet.ahrq.gov/issue/ex…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45882/psn-pdf
    June 28, 2017 - Early death after discharge from emergency departments: analysis of national US insurance claims data. June 28, 2017 Obermeyer Z, Cohn B, Wilson M, et al. Early death after discharge from emergency departments: analysis of national US insurance claims data. BMJ. 2017;356:j239. doi:10.1136/bmj.j239. https://psnet.a…

  15. Appendix B3: Fax Alert | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/fax.html
    February 01, 2023 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities Appendix B3: Fax Alert Previous Page Next Page Table of Contents The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities Chapter 1. Introduction and Program Overview Chapter 2. Fal…

  16. CEO and Senior Leader Checklist | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cusp/toolkit/ceo-snr-leader-chcklst.html
    December 01, 2012 - CEO and Senior Leader Checklist CUSP Toolkit Checklists for senior leadership Who should use this tool? Senior leaders. Checklist items Leader Responsible Date Initiated 1. Ensure all current and new employees receive Science of Safety training.     2. Assign a senior executive …

  17. Ceosnrleaderchcklst (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/ceosnrleaderchcklst.docx
    June 02, 2025 - CEO/Senior Leader Checklist Who should use this tool? Senior leaders. Checklist Items Leader Responsible Date Initiated 1. Ensure all current and new employees receive Science of Safety training. 2. Assign a senior executive (Chief Executive Officer or another leader) as an active member of each

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43486/psn-pdf
    September 01, 2016 - Indication alerts intercept drug name confusion errors during computerized entry of medication orders. September 1, 2016 Galanter W, Bryson M, Falck S, et al. Indication alerts intercept drug name confusion errors during computerized entry of medication orders. PLoS One. 2014;9(7):e101977. doi:10.1371/journal.pone…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43224/psn-pdf
    June 11, 2014 - Look alike/sound alike drugs: a literature review on causes and solutions. June 11, 2014 Ciociano N, Bagnasco L. Look alike/sound alike drugs: a literature review on causes and solutions. Int J Clin Pharm. 2014;36(2):233-242. doi:10.1007/s11096-013-9885-6. https://psnet.ahrq.gov/issue/look-alikesound-alike-drugs-l…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39069/psn-pdf
    February 18, 2011 - Did duty hour reform lead to better outcomes among the highest risk patients? February 18, 2011 Volpp KG, Rosen AK, Rosenbaum PR, et al. Did duty hour reform lead to better outcomes among the highest risk patients? J Gen Intern Med. 2009;24(10):1149-55. doi:10.1007/s11606-009-1011-z. https://psnet.ahrq.gov/issue/d…
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