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psnet.ahrq.gov/node/60042/psn-pdf
March 11, 2020 - At Walgreens, complaints of medication errors go
missing.
March 11, 2020
Gabler E. New York Times. February 23, 2020.
https://psnet.ahrq.gov/issue/walgreens-complaints-medication-errors-go-missing
Response to reported safety concerns is a primary indicator of an organizational commitment to reducing
and lear…
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psnet.ahrq.gov/node/40516/psn-pdf
July 15, 2013 - Characteristics of unsafe undergraduate nursing students
in clinical practice: an integrative literature review.
July 15, 2013
Killam LA, Luhanga F, Bakker D. Characteristics of unsafe undergraduate nursing students in clinical
practice: an integrative literature review. J Nurs Educ. 2011;50(8):437-46. doi:10.3928/…
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psnet.ahrq.gov/taxonomy/term/3437
May 23, 2025 - Adverse Event
Any injury caused by medical care. Examples: pneumothorax from central venous catheter placement anaphylaxis to penicillin postoperative wound infection hospital-acquired delirium (or "sundowning") in elderly patients Identifying something as an adverse event does not imply "error," "negligence," or po…
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hcup-us.ahrq.gov/toolssoftware/comorbidityicd10/comorbidity_icd10.jsp
September 01, 2025 - The Elixhauser Comorbidity Software Refined for ICD-10-CM is one in a family of databases and software tools developed as part of the Healthcare Cost and Utilization Project (HCUP) , a Federal-State-Industry partnership sponsored by the Agency for Healthcare Research and Quality. HCUP databases, tools, and software in…
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digital.ahrq.gov/ahrq-funded-projects/preventing-wrong-drug-and-wrong-patient-errors-indication-alerts-cpoe-systems/citation/effect
January 01, 2023 - Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department.
Citation
Kannampallil TG, Manning JD, Chestek DW, Adelman J, Salmasian H, Lambert BL, Galanter WL. Effect of number of open charts on intercepted wrong-patient medication orders in an emergency …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-f.docx
June 02, 2025 - PROMPTLY REMOVE
AHRQ Safety Program for Reducing CAUTI in Hospitals
Appendix F. Urinary Catheter Decision-Making Algorithm
Is there a urinary catheter in place?
Does the patient meet criteria for catheter placement?
Avoid catheter placement.
Accepted Urinary Catheter
Placement Indications
1. Acute urinary retentio…
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/mui/screening-workflow.pdf
June 02, 2025 - Urinary Incontinence Primary Care Screening Workflow
```
Urinary Incontinence
Primary Care
Screening Workflow
IT2 Team – Northwestern Medicine
This project was funded under grant number U18HS028744
from the …
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-166-fecc-table-6.pdf
June 02, 2025 - Section 6, Table 6 Construct Measurement Reliability Testing
Table 6: Construct measurement reliability testing for multi-part indicators
Number
of items
Average
inter-item
polychoric
correlation
Polychoric
Ordinal
Alp…
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psnet.ahrq.gov/node/47649/psn-pdf
January 09, 2019 - ASH Clinical Practice Guidelines on Venous
Thromboembolism.
January 9, 2019
Washington DC; American Society of Hematology.
https://psnet.ahrq.gov/issue/ash-clinical-practice-guidelines-venous-thromboembolism
The American Society of Hematology produced a series of guidelines on prophylaxis for venous
thromboemboli…
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psnet.ahrq.gov/web-mm/see-patient-first
September 27, 2023 - instability, suspected catheter infection, skin and soft tissue infection, pneumonia, or severe mucositis can indicate
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www.ahrq.gov/sites/default/files/2024-01/hollingsworth-report.pdf
January 01, 2024 - Values closer to 1 indicate higher levels of clustering in the network.
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - SPOTLIGHT CASE
Getting to the Root of the Matter
Citation Text:
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Schola…
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hcup-us.ahrq.gov/reports/statbriefs/sb25.jsp
January 01, 2007 - Statistical Brief #25
An official website of the Department of Health & Human Services
Search All AHRQ Websites
Careers
Contact Us
Espanol
FAQs
Email Updates
…
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Getting to the Root of the Matter
June 1, 2005
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/getting-root-matter
Case Objectives
Appreciate the goals and limitations of root cause analysis
Outline the steps to conduct root cause analysis
The Case
A…
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psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
March 01, 2015 - In Conversation With… Brian Jarman, PhD
March 1, 2015
Also Read an Essay
Citation Text:
In Conversation With… Brian Jarman, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy…
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight11.html
April 01, 2015 - How are CHIPRA quality demonstration States using quality reports to drive health care improvements for children?
Evaluation Highlight No. 11
Authors: Grace Anglin and Mynti Hossain
Contents
Key Messages
Background
Findings
Conclusion
Implications
Learn More
Endnotes
The CHIPRA Qua…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/tool-safe-mgso4.html
July 01, 2023 - Safe Medication Administration: Magnesium Sulfate
AHRQ Safety Program for Perinatal Care
Purpose of the tool: This tool describes the key perinatal safety elements with examples for the safe administration of magnesium sulfate during labor. The key elements are presented within the framework of t…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/nephropathy-contrast-induced_disposition-comments.pdf
January 07, 2016 - We have added information to indicate
that there was another IOCM called iotrolan. … Do
you indicate what the control was?
This figure was revised. … to “Placebo” as this is the more
appropriate description.
53 Technical
Expert #3
Results You indicate … The intro includes a short discussion on LOCM vs IOCM- I might
indicate that a separate report was issued … If the authors actually have data to indicate that high osmolar contrast is
no longer used anywhere;
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/insulin-analogues-disposition-081229.pdf
September 01, 2008 - That would indicate that this is based on our (informal,
undocumented) survey of common usage or beliefs … The authrors need to indicate just what aspect of this kind of therapy is unclear, or
presumably unclea … A "+" or sign or filled circle might
indicate the premixed form is better, a "-" sign or empty circle … An alternative might be to more
clearly indicate in figures those studies in which the comparison involves … I
indicate these in my comments below.
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digital.ahrq.gov/sites/default/files/docs/resource/Logan_QMforColonoscopy_Narrative_v4.pdf
December 12, 2008 - in "Depth of insertion : Actually reached"
by values 'Cecum' or 'Terminal ileum'; any other values indicate … 'Carcinoma' in the Results field of the Pathology list on the Postprocedure page
contains the will indicate … in "Depth of insertion : Actually reached"
by values 'Cecum' or 'Terminal ileum'; any other values indicate … • Details that indicate polypectomy may include choosing 'Totally removed' or
'Removed piecemeal' … in "Depth of insertion : Actually reached"
by values 'Cecum' or 'Terminal ileum'; any other values indicate