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9881. Low Tidal Volume Ventilation Facts | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-fact-sheet.html
      January 01, 2017 - Low Tidal Volume Ventilation Facts AHRQ Safety Program for Mechanically Ventilated Patients Did You Know? Low tidal volume ventilation (LTVV) is one of the interventions specifically designed to prevent ventilator-associated conditions (VAC).  For patients without acute respiratory distress …

9882. Event Investigation and Analysis Guide: Appendix D | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
      August 01, 2022 - Event Investigation and Analysis Guide: Appendix D CANDOR Tool PROCESS QUESTIONS TO REVIEW Y/N CONTRIBUTING OR CAUSAL FACTOR Y/N FINDINGS / COMMENTS COMMUNICATION Did all caregivers have access to all pertinent information needed to make the best decisions for the patient? (e.g.,…

9883. Data Submission Dashboard Data 2025 (xls file)
      www.ahrq.gov/sites/default/files/wysiwyg/npsd/Data_Submission_Dashboard_Data_2025.xlsx
      January 01, 2025 - Introduction Introduction-Data Submission Summary The tables in this workbook present data submitted by AHRQ-listed Patient Safety Organizations (PSOs) to the Network of Patient Safety Databases (NPSD) through December 31, 2024. The tables include distributions of events and unsafe conditions reported by PSOs using …

9884. The potential for leveraging machine learning to filter medication alerts. | PSNet
      psnet.ahrq.gov/issue/potential-leveraging-machine-learning-filter-medication-alerts
      July 22, 2020 - Study The potential for leveraging machine learning to filter medication alerts. Citation Text: Liu S, Kawamoto K, Del Fiol G, et al. The potential for leveraging machine learning to filter medication alerts. J Am Med Inform Assoc. 2022;29(5):891-899. doi:10.1093/jamia/ocab292. Copy Ci…

9885. "Good catch, Kiddo"--enhancing patient safety in the pediatric emergency department through simulation. | PSNet
      psnet.ahrq.gov/issue/good-catch-kiddo-enhancing-patient-safety-pediatric-emergency-department-through-simulation
      January 03, 2017 - Study "Good catch, Kiddo"--enhancing patient safety in the pediatric emergency department through simulation. Citation Text: Shaikh U, Natale JAE, Till DA, et al. "Good catch, Kiddo"--enhancing patient safety in the pediatric emergency department through simulation. Pediatr Emerg Care. 2…

9886. Assessment of opioid prescribing practices before and after implementation of a health system intervention to reduce opioid overprescribing. | PSNet
      psnet.ahrq.gov/issue/assessment-opioid-prescribing-practices-and-after-implementation-health-system-intervention
      November 16, 2022 - Study Emerging Classic Assessment of opioid prescribing practices before and after implementation of a health system intervention to reduce opioid overprescribing. Citation Text: Meisenberg BR, Grover J, Campbell C, et al. Assessment of Opioid Prescribing Practi…

9887. Physician EHR adoption and potentially preventable hospital admissions among Medicare beneficiaries: panel data evidence, 2010–2013. | PSNet
      psnet.ahrq.gov/issue/physician-ehr-adoption-and-potentially-preventable-hospital-admissions-among-medicare
      February 14, 2024 - Study Physician EHR adoption and potentially preventable hospital admissions among Medicare beneficiaries: panel data evidence, 2010–2013. Citation Text: Lammers EJ, McLaughlin CG, Barna M. Physician EHR Adoption and Potentially Preventable Hospital Admissions among Medicare Beneficiarie…

9888. Advance care planning documentation practices and accessibility in the electronic health record: implications for patient safety. | PSNet
      psnet.ahrq.gov/issue/advance-care-planning-documentation-practices-and-accessibility-electronic-health-record
      December 05, 2012 - Study Emerging Classic Advance care planning documentation practices and accessibility in the electronic health record: implications for patient safety. Citation Text: Walker E, McMahan R, Barnes D, et al. Advance Care Planning Documentation Practices and Access…

9889. Residency work-hours reform: a cost analysis including preventable adverse events. | PSNet
      psnet.ahrq.gov/issue/residency-work-hours-reform-cost-analysis-including-preventable-adverse-events
      August 05, 2015 - Study Residency work-hours reform: a cost analysis including preventable adverse events. Citation Text: Nuckols TK, Escarce JJ. Residency work-hours reform. A cost analysis including preventable adverse events. J Gen Intern Med. 2005;20(10):873-8. Copy Citation Format: Go…

9890. Non-intercepted dose errors in prescribing antineoplastic treatment: a prospective, comparative cohort study. | PSNet
      psnet.ahrq.gov/issue/non-intercepted-dose-errors-prescribing-antineoplastic-treatment-prospective-comparative
      June 18, 2013 - Study Non-intercepted dose errors in prescribing antineoplastic treatment: a prospective, comparative cohort study. Citation Text: Mattsson TO, Holm B, Michelsen H, et al. Non-intercepted dose errors in prescribing anti-neoplastic treatment: a prospective, comparative cohort study. Ann O…

9891. Surgical glove perforation and the risk of surgical site infection. | PSNet
      psnet.ahrq.gov/issue/surgical-glove-perforation-and-risk-surgical-site-infection
      March 02, 2011 - Study Surgical glove perforation and the risk of surgical site infection. Citation Text: Misteli H, Weber WP, Reck S, et al. Surgical glove perforation and the risk of surgical site infection. Arch Surg. 2009;144(6):553-8; discussion 558. doi:10.1001/archsurg.2009.60. Copy Citation …

9892. Abstract | Agency for Healthcare Research and Quality
      www.ahrq.gov/policymakers/chipra/measure_retirement/measure_retirement1.html
      February 01, 2014 - Background Report on 2013 Retirement of Measures from the Child Core Set Abstract Previous Page Next Page Table of Contents Background Report on 2013 Retirement of Measures from the Child Core Set Abstract Background Methods Results Conclusions References Appendix A. Appendix B. …

9893. Persistent opioid use among pediatric patients after surgery. | PSNet
      psnet.ahrq.gov/issue/persistent-opioid-use-among-pediatric-patients-after-surgery
      January 29, 2020 - Study Classic Persistent opioid use among pediatric patients after surgery. Citation Text: Harbaugh CM, Lee JS, Hu HM, et al. Persistent Opioid Use Among Pediatric Patients After Surgery. Pediatrics. 2018;141(1):e20172439. doi:10.1542/peds.2017-2439. Copy Cita…

9894. Deaths among opioid users: impact of potential inappropriate prescribing practices. | PSNet
      psnet.ahrq.gov/issue/deaths-among-opioid-users-impact-potential-inappropriate-prescribing-practices
      October 19, 2011 - Study Deaths among opioid users: impact of potential inappropriate prescribing practices. Citation Text: Jayawardhana J, Abraham AJ, Perri M. Deaths among opioid users: impact of potential inappropriate prescribing practices. Am J Manag Care. 2019;25(4):e98-e103. Copy Citation Form…

9895. An observational study of adult admissions to a medical ICU due to adverse drug events. | PSNet
      psnet.ahrq.gov/issue/observational-study-adult-admissions-medical-icu-due-adverse-drug-events
      January 28, 2015 - Study An observational study of adult admissions to a medical ICU due to adverse drug events. Citation Text: Jolivot P-A, Pichereau C, Hindlet P, et al. An observational study of adult admissions to a medical ICU due to adverse drug events. Ann Intensive Care. 2016;6(1):9. doi:10.1186/s1…

9896. AHRQ's Patient Safety Culture Survey Yields Meaningful Results at Palo Alto Medical Foundation | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsroom/case-studies/cquips0603.html
      October 01, 2014 - AHRQ's Patient Safety Culture Survey Yields Meaningful Results at Palo Alto Medical Foundation Search All Impact Case Studies November 2005 The Palo Alto Medical Foundation, a multi-specialty medical group located near San Francisco, is now using AHRQ's Hospital Survey on Patient Safety Culture . The first…

9897. An embedded checklist in the Anesthesia Information Management System improves pre-anaesthetic induction setup: a randomised controlled trial in a simulation setting. | PSNet
      psnet.ahrq.gov/issue/embedded-checklist-anesthesia-information-management-system-improves-pre-anaesthetic
      June 26, 2019 - Study An embedded checklist in the Anesthesia Information Management System improves pre-anaesthetic induction setup: a randomised controlled trial in a simulation setting. Citation Text: Wetmore D, Goldberg A, Gandhi N, et al. An embedded checklist in the Anesthesia Information Manageme…

9898. Introduction | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-2.html
      June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Introduction Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Introduct…

9899. Getting the board on board: engaging hospital boards in quality and patient safety. | PSNet
      psnet.ahrq.gov/issue/getting-board-board-engaging-hospital-boards-quality-and-patient-safety
      November 23, 2016 - Study Getting the board on board: engaging hospital boards in quality and patient safety. Citation Text: Joshi MS, Hines S. Getting the board on board: Engaging hospital boards in quality and patient safety. Jt Comm J Qual Patient Saf. 2006;32(4):179-87. Copy Citation Format: …

9900. Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures. | PSNet
      psnet.ahrq.gov/issue/prospective-evaluation-consultant-surgeon-sleep-deprivation-and-outcomes-more-4000
      October 19, 2022 - Study Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures. Citation Text: Chu MWA, Stitt LW, Fox SA, et al. Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 cons…