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241. Impact of alarm fatigue on the work of nurses in an intensive care environment--a systematic review. | PSNet
     psnet.ahrq.gov/issue/impact-alarm-fatigue-work-nurses-intensive-care-environment-systematic-review
     August 31, 2022 - Alarm fatigue , which can lead to desensitization and threaten  patient safety , is particularly concerning … January 25, 2023 Can the standard configuration of a cardiac monitor lead to medical

242. Investigating Interventions to Reduce Unsafe Use of Antibiotics | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-grigoryan.html
     November 01, 2024 - is vitally important to both individual and public health because inappropriate antibiotic use can lead … She is the lead investigator on a 5-year AHRQ  grant awarded in 2023.

243. Figure 2: Framework for Stroke Rehabilitation | Agency for Healthcare Research and Quality
     www.ahrq.gov/prevention/resources/vision/visfig2.html
     October 01, 2002 - in the framework shows that physiological changes resulting from an underlying disease or injury may lead … In the instance of stroke, brain tissue is damaged from a lack of blood flow, which may lead to a limitation

244. Action Planning for the SOPS Surveys-Introducing SOPS (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-gray-sops-action-planning-tool.pdf
     June 02, 2025 - Who can lead the initiative? … Who can lead the initiative? 6. What resources will be needed? 7. What are possible barriers? 8.

245. Surgical Safety Team Roles and Responsibilities Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/surgical_roles.docx
     December 01, 2017 - Implement Teamwork Tools Who will lead the implementation of briefings, debriefings, and other teamwork … Implementation of Practice Changes Who will lead efforts to align practice with evidence-based guidelines

246. CAHPS® Moving Forward: Innovations in Tools and Research Webcast (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-moving-forward-cleary-slides.pdf
     March 01, 2010 - et al. 2010) • Providers may pay greatest attention to patients near the end of life, which would lead … Does Providing Unwelcome Advice Lead to Lower Patient Care Scores? 2. … want to hear smoking cessation advice • Concern about receiving poor experience of care scores may lead … Does Providing Unwelcome Advice Lead to Lower Patient Care Scores? 2. … patient-centered care that providers can, and do, improve • Improving patient experiences does not lead

247. Supporting Patient and Consumer Involvement in Patient-Centered Outcomes Research (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/lavallee-text.pdf
     October 13, 2011 - SRA International § Support for Patient and Consumer Representatives § Amy Bonoff, NBCC Project LEAD … Technical Expert Panel (TEP) Members Affiliation Amy Bonoff National Breast Cancer Coalition Project LEAD … SRA International § Support for Patient and Consumer Representatives § Amy Bonoff, NBCC Project LEAD

248. Slide 1 (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/cf_intro_ehc_cf_overview_1012.pdf
     October 13, 2011 - SRA International ─ Support for Patient and Consumer Representatives  Amy Bonoff, NBCC Project LEAD … Technical Expert Panel (TEP) Members Affiliation Amy Bonoff National Breast Cancer Coalition Project LEAD … SRA International Support for Patient and Consumer Representatives ─ Amy Bonoff, NBCC Project LEAD

249. A Fatal Twist in Pseudohyperkalemia | PSNet
     psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
     February 10, 2021 - His 12-lead electrocardiogram (ECG) demonstrated normal sinus rhythm and right bundle branch block (RBBB … Lewis, MD This case illustrates how the misinterpretation of a common laboratory complication can lead … In this 12-lead ECG, hypokalemia is evidenced by prominent U waves (red arrows) and T wave inversions … Clinicians should have a low threshold to repeat diagnostic testing such as routine bloodwork and 12-lead … WebM&M Cases Missing ECG and Missed Diagnosis Lead

250. Clinical Decision Support Authoring Tool | Digital Healthcare Research
     digital.ahrq.gov/national-webinars/clinical-decision-support-authoring-tool
     January 01, 2023 - Speakers: Sharon Sebastian CDS Connect Project Lead MITRE Chris … Moesel CDS Connect Technical Lead MITRE Moderator: Edwin Lomotan

251. OY2 Innovation Center Operational Framework (pdf file)
     cdsic.ahrq.gov/sites/default/files/2024-12/OY2%20Innovation%20Center%20Operational%20Framework_508.pdf
     January 01, 2024 - Leadership Principal Investigator Prashila Dullabh from NORC at the University of Chicago (NORC) will lead … She will work in partnership with Core 1 Lead Dean Sittig (University of Texas Health) and Core 2 Lead … President, Health Informatics Research, Elimu Informatics Marc Overhage, MD, PhD, Chief Health Informatics Lead … ■ The lead author is generally the individual responsible for writing the first draft of the manuscript … ■ The CDSiC PI or Stakeholder Center lead will serve as the corresponding author.

252. Five Medication Safety Tips for Older Adults. | PSNet
     psnet.ahrq.gov/issue/five-medication-safety-tips-older-adults
     April 23, 2012 - Highlighting how aging affects medication absorption that may lead to complications, this fact sheet … , 2012 Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead

253. Disclosure Policy and Form (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/epc-disclosure-policy-form.pdf
     March 01, 2023 - to the subject matter, including (as relevant): a) EPC Core Team (including the EPC Director and Lead … In many cases, the EPC Director may designate one person as the Lead Investigator and delegate some … EPC Lead Investigator: If the EPC Director chooses, he or she may assign a separate Lead Investigator … If an individual's involvement in the project lasts longer than 12 months, the EPC Director (or Lead … EPC Lead Investigator: If the EPC Director chooses, he or she may assign a separate Lead Investigator

254. What We Learned: Five Key Lessons | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/clabsi-final/clabsifinal4.html
     January 01, 2013 - National content calls and State lead meetings featured CDC and HHS as faculty to explain data definitions … The NPT held monthly State lead calls in which State leads could share their experiences and strategies … This manifested itself in how the NPT advised States on monthly State lead calls and in using faculty … from HHS and CDC to present to unit teams and at State lead meetings.

255. Fatal gas line mix-up: How to avoid making this "gastly" mistake. | PSNet
     psnet.ahrq.gov/issue/fatal-gas-line-mix-how-avoid-making-gastly-mistake
     April 29, 2018 - Related Resources From the Same Author(s) Loud wake-up call: unlabeled containers lead … April 29, 2018 Administering a saline flush "site unseen" can lead to a wrong route error … , 2018 Smart pump custom concentrations without hard "low concentration" alerts can lead

256. Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. | PSNet
     psnet.ahrq.gov/issue/changes-prescription-and-over-counter-medication-and-dietary-supplement-use-among-older
     May 06, 2020 - Older adults commonly use over-the-counter medications and dietary supplements , which can lead to … June 19, 2019 Polypharmacy in the elderly--when good drugs lead to bad outcomes: a teachable

257. The Culture of Culturing—The Importance of Knowing When To Order Urine Cultures | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/urine-culturing/when-to-order/cultures-slides.html
     April 01, 2017 - completion of this training, participants will be able to— Explain why unnecessary urine cultures can lead … Slide 3: How Can Ordering Urine Cultures Lead To Resident Harms? … Image: Flow chart showing how urinary catheters and unnecessary urine cultures can lead to resident harms … Similarly, inappropriate ordering of urine cultures can lead to improper use of antibiotics.

258. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838220/psn-pdf
     September 27, 2019 - AHRQ, as one of the lead federal agencies in primary care research, funds research to understand how … AHRQ is the lead federal agency for patient safety research. … ’s, describing 7C’s,9 9C’s,10 or even 10C’s.11 These models all identify functions that ultimately lead … evidence- informed care, avoidance of low- value care Ineffective allocation of resources could lead … low or no value (cost- effectiveness) Engaging in value-based care Inefficient care delivery may lead

259. Kick-off Visit Check List (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/skills-qi-kickoff.pdf
     June 02, 2025 - notes in Electronic Practice Record  Write plan for Kick-Off in EPR   Distribute dashboards per lead … in Electronic Practice Record: Off Write plan for Kick-Off in EPR: Off Distribute dashboards per lead

260. TeamSTEPPS® Helps St. Louis Hospital Keep C-Section Rate Low | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201904.html
     June 01, 2019 - For every labor and delivery patient, the charge nurse and chief resident lead an interdisciplinary team … Labor and delivery units are high-risk environments where one miscommunication can lead to care breakdowns