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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/learn_from_defects.docx
December 01, 2017 - Learn From Defects Tool
AHRQ Safety Program for Surgery
Learn From Defects Tool – Perioperative Setting
What is a defect? A defect is any event or situation that you don’t want to repeat. This could include an incident that caused patient harm or put patients at risk for harm, such as a patient fall.
Problem statem…
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/about/ncepcr-older-adults-presentation.pptx
March 15, 2025 - Approaches to Address Health Risks for Older Adults
National Center for Excellence in Primary Care
1
National Center for Excellence in Primary Care Research
Presents
Approaches to Address Health Risks for Older Adults
January 16, 2025
Presented by:
Lisa Kern, MD, MPH
Alberta K. Tran, Ph.D., RN, CCRN
Yu-J…
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psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
August 01, 2017 - The Evolution of Patient Safety in Surgery
Robert M. Wachter, MD | December 1, 2017
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Wachter R. The Evolution of Patient Safety in Surgery. PSNet [internet]. Rockville (MD): Agency…
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening-2002
December 01, 2002 - Share to Facebook
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archived
Recommendations and Rationale
Prostate Cancer: Screening, 2002
December 01, 2002
Recommendations made by the USPSTF are independent of the U.S. government. They…
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hcup-us.ahrq.gov/reports/statbriefs/sb117.jsp
June 01, 2011 - Statistical Brief #117
An official website of the Department of Health & Human Services
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Woolever.pdf
January 01, 2001 - The Impact of a Patient Safety Program on Medical Error Reporting
307
The Impact of a Patient Safety Program
on Medical Error Reporting
Donald R. Woolever
Abstract
Background: In response to the occurrence of a sentinel event—a medical error
with serious consequences—Eglin U.S. Air Force (USAF) Regional Hos…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
May 19, 2003 - Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis
323
Improving the Safety of Heparin
Administration by Implementing a
Human Factors Process Analysis
Kathleen A. Harder, John R. Bloomfield,
Sue E. Sendelbach, Michele F. Shepherd, Pam S. Rush,
Jamie S. Sinclair,…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kaprielian_9.pdf
January 01, 2007 - A System to Describe and Reduce Medical Errors in Primary Care
A System to Describe and Reduce Medical Errors in
Primary Care
Victoria Kaprielian, MD; Truls Østbye, MD, PhD; Samuel Warburton, MD;
Devdutta Sangvai, MD, MBA; Lloyd Michener, MD
Abstract
Although much attention has been focused on finding wa…
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hcup-us.ahrq.gov/reports/statbriefs/sb164.pdf
October 01, 2013 - Characteristics of Adverse Drug Events Originating During the Hospital Stay, 2011
1
October 2013
Characteristics of Adverse Drug Events
Originating During the Hospital Stay, 2011
Audrey J. Weiss, Ph.D. and Anne Elixhauser, Ph.D.
Introduction
An adverse drug event (ADE) involves patient in…
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hcup-us.ahrq.gov/reports/statbriefs/sb156.jsp
May 01, 2013 - Statistical Brief #156
An official website of the Department of Health & Human Services
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hcup-us.ahrq.gov/reports/statbriefs/sb125.pdf
February 01, 2012 - Statistical Brief #125: Cancer Hospitalizations for Adults, 2009
1
February 2012
Cancer Hospitalizations for Adults, 2009
Rebecca Anhang Price, PhD, Elizabeth Stranges, MS, Anne
Elixhauser, PhD
Introduction
Cancer is the leading cause of death among men and women
under age 85.1 The most c…
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hcup-us.ahrq.gov/reports/statbriefs/sb25.pdf
January 01, 2007 - HCUP Statistical Brief #160: Hospital Stays for Burns, 2004
HEALTHCARE COST AND
UTILIZATION PROJECT
Agen
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January 2007
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while
ac…
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hcup-us.ahrq.gov/reports/statbriefs/sb46.pdf
January 16, 2008 - Statistical Brief #46: Hospitalizations for Epilepsy and Convulsions, 2005
HEALTHCARE COST AND
UTILIZATION PROJECT Agen
Rese
Highli
In 2005, nearly
hospital stays i
epilepsy or con
diagnosis. Abo
had epilepsy or
the principal re
hospitalization,
$1.8 billion in h
The number of
relate…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/chronic-pain-opioid-treatment_disposition-comments.pdf
September 29, 2014 - Disposition of Comments Report for The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain
Evidence Report Disposition of Comments Report
Research Review Title: The Effectiveness and Risks of Long-Term Opioid Treatment
of Chronic Pain
Draft review available for public comment from De…
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psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - SPOTLIGHT CASE
Two Wrongs Don't Make a Right (Kidney)
Citation Text:
DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - Acute Respiratory Arrest in Pregnancy
Citation Text:
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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digital.ahrq.gov/ahrq-funded-projects/context-aware-knowledge-delivery-electronic-health-records
January 01, 2023 - Context-Aware Knowledge Delivery into Electronic Health Records
Project Final Report ( PDF , 549.92 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 view…
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psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
February 23, 2011 - Patient Identification Errors: A Systems Challenge
Citation Text:
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - Medical Devices in the "Wild"
Citation Text:
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/72834/psn-pdf
March 10, 2021 - Approach to Improving Patient Safety: Communication
March 10, 2021
Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet
[internet]. 2021.
https://psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
Introduction
Each one of the countless necessa…