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psnet.ahrq.gov/issue/frequent-diagnostic-errors-cardiac-petct-due-misregistration-ct-attenuation-and-emission-pet
December 22, 2018 - Study
Frequent diagnostic errors in cardiac PET/CT due to misregistration of CT attenuation and emission PET images: a definitive analysis of causes, consequences, and corrections.
Citation Text:
Gould L, Pan T, Loghin C, et al. Frequent diagnostic errors in cardiac PET/CT due to misre…
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psnet.ahrq.gov/issue/principles-patient-and-family-partnership-care-american-college-physicians-position-paper
March 14, 2018 - Commentary
Emerging Classic
Principles for Patient and Family Partnership in Care: An American College of Physicians Position Paper.
Citation Text:
Nickel WK, Weinberger SE, Guze PA, et al. Principles for Patient and Family Partnership in Care: An American Colle…
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psnet.ahrq.gov/issue/medication-errors-associated-transition-insulin-pens-insulin-vials
May 29, 2019 - Study
Medication errors associated with transition from insulin pens to insulin vials.
Citation Text:
Trimble AN, Bishop B, Rampe N. Medication errors associated with transition from insulin pens to insulin vials. Am J Health Syst Pharm. 2017;74(2):70-75. doi:10.2146/ajhp150726.
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psnet.ahrq.gov/issue/computer-physician-order-entry-benefits-costs-and-issues
May 27, 2011 - Study
Computer physician order entry: benefits, costs, and issues.
Citation Text:
Kuperman GJ, Gibson RF. Computer physician order entry: benefits, costs, and issues. Ann Intern Med. 2003;139(1):31-9.
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psnet.ahrq.gov/issue/current-approaches-punitive-action-medication-errors-boards-pharmacy
May 26, 2011 - Study
Current approaches to punitive action for medication errors by boards of pharmacy.
Citation Text:
Holdsworth M, Wittstrom K, Yeitrakis T. Current approaches to punitive action for medication errors by boards of pharmacy. Ann Pharmacother. 2013;47(4):475-81. doi:10.1345/aph.1R668. …
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psnet.ahrq.gov/issue/there-evidence-july-effect-among-patients-undergoing-hysterectomy-surgery
April 24, 2018 - Study
Is there evidence of a July effect among patients undergoing hysterectomy surgery?
Citation Text:
Varma S, Mehta A, Hutfless S, et al. Is there evidence of a July effect among patients undergoing hysterectomy surgery? Am J Obstet Gynecol. 2018;219(2):176.e1-176.e9. doi:10.1016/j.aj…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/uti-one-pager.pdf
September 01, 2022 - Urinary Tract Infections
Urinary Tract Infections
Diagnosis
• First, ask about symptoms
o Acute cystitis: dysuria, frequency, urgency, suprapubic pain
o Pyelonephritis: fever, flank pain
o Sending a urine culture in the absence of symptoms is indicated …
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psnet.ahrq.gov/issue/review-current-evidence-base-significant-event-analysis
October 14, 2009 - Review
A review of the current evidence base for significant event analysis.
Citation Text:
Bowie P, Pope L, Lough M. A review of the current evidence base for significant event analysis. J Eval Clin Pract. 2008;14(4):520-36. doi:10.1111/j.1365-2753.2007.00908.x.
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psnet.ahrq.gov/issue/does-surgeon-fatigue-influence-outcomes-after-anterior-resection-rectal-cancer
August 04, 2021 - Study
Does surgeon fatigue influence outcomes after anterior resection for rectal cancer?
Citation Text:
Schieman C, MacLean AR, Buie D, et al. Does surgeon fatigue influence outcomes after anterior resection for rectal cancer? Am J Surg. 2008;195(5):684-7; discussion 687-8. doi:10.101…
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www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/resources/qapi-leadership-rounding-guide-centers-for-medicare.pdf
June 02, 2025 - QAPI Leadership Rounding Guide
Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance.
Directions: Leadership rounding is a process where leaders (e.g., administrator, department heads, and nurse
managers) are out in the building with staff and residents, t…
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psnet.ahrq.gov/issue/really-stupid-mistake-it-does-feel-cop-out-blame-my-error-human-frailty-im-afraid-thats
August 16, 2023 - Commentary
A really stupid mistake: it does feel like a cop out to blame my error on human frailty, but I'm afraid that's exactly what it was.
Citation Text:
Maskell G. A really stupid mistake: it does feel like a cop out to blame my error on human frailty, but I'm afraid that's exactly …
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psnet.ahrq.gov/issue/patient-safety-otolaryngology-descriptive-review
July 14, 2010 - Review
Patient safety in otolaryngology: a descriptive review.
Citation Text:
Danino J, Muzaffar J, Metcalfe C, et al. Patient safety in otolaryngology: a descriptive review. Eur Arch Otorhinolaryngol. 2017;274(3):1317-1326. doi:10.1007/s00405-016-4291-z.
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psnet.ahrq.gov/issue/biopsy-site-selfies-quality-improvement-pilot-study-assist-correct-surgical-site
August 02, 2015 - Study
Biopsy site selfies—a quality improvement pilot study to assist with correct surgical site identification.
Citation Text:
Nijhawan RI, Lee EH, Nehal KS. Biopsy site selfies--a quality improvement pilot study to assist with correct surgical site identification. Dermatol Surg. 2015;4…
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psnet.ahrq.gov/issue/obstetrician-gynecologists-opinions-about-patient-safety-costs-and-liability-remain-problems
November 25, 2009 - Study
Obstetrician-gynecologists' opinions about patient safety: costs and liability remain problems; are mandated reports a solution?
Citation Text:
Stumpf PG, Anderson B, Lawrence H, et al. Obstetrician-gynecologists' opinions about patient safety: costs and liability remain problems…
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psnet.ahrq.gov/issue/critical-care-transition-programs-and-risk-readmission-or-death-after-discharge-icu
October 13, 2018 - Review
Critical care transition programs and the risk of readmission or death after discharge from an ICU: a systematic review and meta-analysis.
Citation Text:
Niven DJ, Bastos JF, Stelfox HT. Critical care transition programs and the risk of readmission or death after discharge from …
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psnet.ahrq.gov/issue/systematic-review-malpractice-litigation-diagnosis-and-treatment-acute-stroke
October 19, 2022 - Journal Article
Systematic review of malpractice litigation in the diagnosis and treatment of acute stroke
Citation Text:
Haslett JJ, Genadry L, Zhang X, et al. Systematic Review of Malpractice Litigation in the Diagnosis and Treatment of Acute Stroke. Stroke. 2019;50(10):2858-2864. doi:…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/medical-office/mowebinar_2014/funaro-0914slides.pdf
January 01, 2014 - Success Stories from the AHRQ Medical Office Survey on Patient Safety Culture
45
45
YUMA DISTRICT HOSPITAL AND
CLINICS
Bev Funaro, RN
Director of Quality and Regulatory Affairs
46
46
Yuma Clinic Background
• Participate in the Hospital and Medical Office
surveys
• Administered survey in 2011 and 2…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/duration/chipra-155-section-7-b-icd-9-codes.pdf
June 02, 2025 - CHIPRA 155: Section 7.B, ICD-9 Codes Used in this Analysis
Continuity of Insurance: Coverage Presumed Ineligible
ICD-9 codes for the chronic conditions included in the analysis for this measure are as
follows:
DIABETES 250-250.91
METABOLIC DISORDERS 270–273.9, 275-.9
270 Disorders of amino-acid tra…
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psnet.ahrq.gov/issue/detecting-clinical-medication-errors-ai-enabled-wearable-cameras
August 03, 2022 - Study
Detecting clinical medication errors with AI enabled wearable cameras.
Citation Text:
Chan J, Nsumba S, Wortsman M, et al. Detecting clinical medication errors with AI enabled wearable cameras. NPJ Dig Med. 2024;7(1):287. doi:10.1038/s41746-024-01295-2.
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psnet.ahrq.gov/issue/understanding-interdisciplinary-health-care-teams-using-simulation-design-processes-air
November 25, 2009 - Study
Understanding interdisciplinary health care teams: using simulation design processes from the Air Carrier Advanced Qualification Program to identify and train critical teamwork skills.
Citation Text:
Hamman WR, Beaudin-Seiler BM, Beaubien JM. Understanding interdisciplinary healt…