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www.ahrq.gov/sites/default/files/wysiwyg/topics/ed-boarding-summit-report.pdf
March 01, 2025 - regional health data systems.44 To be
effective, such a data system would need to be accompanied by inter-institutional … Services
Administration
Jessica Smith, MD
Director of Graduate Medical Education
Designated Institutional
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/mrsa-screening-2010_executive.pdf
January 01, 2010 - vascular
17
device infections, initiatives to improve hand hygiene, and
interventions to promote an institutional … paper39 stepped back from
advocating mandatory screening, citing concerns about the
importance of institutional
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs023837-gurses-final-report-2021.pdf
January 01, 2021 - describe an approach for linking electronically
extracted EHR data to trauma registry data at the
institutional … an approach for linking electronically extracted EHR data to pediatric trauma registry
data at the institutional
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-appendix-combined.pdf
October 25, 2022 - 2022 National Healthcare Quality and Disparities Report Appendixes
2022 National Healthcare Quality and
Disparities Report
Appendixes
U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
www.ahrq.gov
AHRQ Publication No. 22(23)-0030
…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/hypertension-drugs-utilization_research.pdf
January 25, 2011 - Utilization of antihypertensive drug classes among
Medicare beneficiaries with hypertension, 2007 to 2009
Cardiovascular Issues Data Points #8
Between 2007 and 2009,
87 to 88 percent of Medicare
beneficiaries with hypertension
used at least one prescription
for an antihypertensive drug.
Beneficiaries with hyp…
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - SPOTLIGHT CASE
Which Line: Ordering Provider or Proceduralist?
Citation Text:
Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format: …
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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - SPOTLIGHT CASE
Suicidal Ideation in the Family Medicine Clinic
Citation Text:
Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
…
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions
Citation Text:
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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Format:
Google Scholar BibTeX EndNote X3 X…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/high-risk-drugs-protocol.pdf
July 27, 2023 - EHC Protocol: Addressing Social Isolation To Improve Health of Older Adults: A Rapid Evidence Review
1
Evidence-based Practice Center Rapid Response Protocol
Project Title: Making Healthcare Safer IV:
Protocols for High-Risk Drugs: Reducing Adverse Drug Events
Related to Anticoagulants
Review Qu…
-
psnet.ahrq.gov/node/865309/psn-pdf
May 29, 2024 - A Stable Airway? Fatal Airway Occlusion After Inadequate
Post-Tracheostomy Care
May 29, 2024
Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-
Tracheostomy Care. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-i…
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/guide2.html
October 01, 2017 - Module 2: How To Manage Change
Training Guide
Module Aim
The aim of this module is to support change in your organization to maximize the possibility of successful implementation of the Pressure Injury Prevention Program.
Module Goals
The goals of Module 2 are to identify necessary actions to improve or…
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psnet.ahrq.gov/web-mm/consequences-medical-overuse
May 05, 2021 - SPOTLIGHT CASE
Consequences of Medical Overuse
Citation Text:
Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibT…
-
psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - Despite Clues, Failed to Rescue
August 1, 2017
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
Case Objectives
Define failure to rescue.
Identify the main contributors to failure-to-rescue events.
Appreciate the ongoing areas of scien…
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psnet.ahrq.gov/web-mm/forgotten-turn
August 01, 2018 - SPOTLIGHT CASE
The Forgotten Turn
Citation Text:
Barbour S. The Forgotten Turn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
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psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - SPOTLIGHT CASE
Don't Dismiss the Dangerous: Obstetric Hemorrhage
Citation Text:
Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
…
-
digital.ahrq.gov/sites/default/files/docs/publication/Parisetal_HFES2008.pdf
January 01, 2008 - Safety of the Antibiotic Medication Use Process in the Intensive Care Unit
Bonnie Paris�, Pascale Carayon�, Tosha Wetterneck�
Department of Industrial & Systems Engineering, University of Wisconsin-Madison�; University of
Wisconsin School of Medicine and Public Health�; Center for Quality & Productivity Improvem…
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs4-computerized-cds-protocol.pdf
May 08, 2023 - EHC Protocol: Addressing Social Isolation To Improve Health of Older Adults: A Rapid Evidence Review
1
Evidence-based Practice Center Rapid Review Protocol
Project Title: Making Healthcare Safer IV: Computerized
Clinical Decision Support to Prevent Medication Errors and
Adverse Drug Events
Review …
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/hospital-length-of-stay-disposition-comments_0.pdf
September 20, 2021 - Disposition of Comments_Technical Brief No. 40: Interventions To Decrease Hospital Length of Stay
Technical Brief Disposition of Comments Report
Title: Interventions To Decrease Hospital Length of Stay
Draft report available for public comment from September 23, 2020, to November 10, 2020.
C…
-
psnet.ahrq.gov/node/50841/psn-pdf
January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near-
Miss Wrong Transfusion Event
January 29, 2020
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…