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281. Final Progress Report: Are Volume Standards Accurate Measures? (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/glance-report.pdf
     January 01, 2024 - Selective avoidance of low-volume centers does not lead to improved outcomes, whereas selective avoidance … routine administrative data without the POA indicator to construct hospital quality report cards may lead … test whether: Regionalizing high-risk surgery by diverting patients from low-quality centers will lead … The inability to separate the two in most administrative databases is likely to lead to biased risk … Selective avoidance of low-volume hospitals would not lead to any improvement in outcomes.

282. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37026/psn-pdf
     September 15, 2011 - residents-feel-unprepared-and-unsupervised-leaders-cardiac-arrest-teams- teaching-hospitals Housestaff traditionally lead … found that most respondents felt that ACLS training alone did not leave them adequately prepared to lead

283. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33808/psn-pdf
     May 01, 2016 - This desensitization can lead to longer response times or to missing important alarms. … Staff education Patient education Artifacts in the Waveform Waveform artifacts can be caused by poor lead … They can also lead to alarms when the monitor falsely perceives arrhythmias. … placement and change the electrodes daily.(6) In addition, proper care and maintenance of lead wires … Hospitals should not only have a policy for electrode changes, but also for monitoring and replacing lead

284. Implementing Automatic Referral | Agency for Healthcare Research and Quality
     www.ahrq.gov/takeheart/training/implementing-automatic-referral/index.html
     April 01, 2023 - Epic Q&A Cerner Q&A Stephen Hines , Ph.D., TAKEheart's Training and Technical Assistance Lead … Session (PDF, 2 MB) Epic Q&A Stephen Hines , Ph.D., TAKEheart's Training and Technical Assistance Lead

285. Error analysis leading technology development. | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/promoting-patient-safety-web-based-patient-profiles/citation/error-analysis
     January 01, 2023 - Error analysis leading technology development. Citation Carstens D. Error analysis leading technology development. TIES 2006;7(6):525-49. Link http://www.tandfonline.com/doi/abs/10.1080/14639220600983856 Principal Investigator Laird, Rosemary Project Name Promoting Patie…

286. Power of saying ‘I Don’t Know’: psychological safety and participatory strategies for healthcare leaders. | PSNet
     psnet.ahrq.gov/issue/power-saying-i-dont-know-psychological-safety-and-participatory-strategies-healthcare-leaders
     August 31, 2011 - BMJ Lead. 2024;Epub Jan 17. doi:10.1136/leader-2023-000906. … BMJ Lead . 2024; Epub Jan 17 . View more articles from the same authors. … BMJ Lead. 2024;Epub Jan 17. doi:10.1136/leader-2023-000906.

287. Regional Health Information Organizations and other Health Information Exchanges: The Value Proposition (pdf file)
     digital.ahrq.gov/sites/default/files/docs/page/2006Lee_051711comp.pdf
     May 01, 2006 - What are the critical factors that lead to the formation and sustainability of RHIOs/HIEs? 3. … What are the critical factors that lead to the formation and sustainability of RHIOs/HIEs? 3. … What are the critical factors that lead to the formation and sustainability of RHIOs/HIEs? 3. … What are the critical factors that lead to the formation and sustainability of RHIOs/HIEs? 3.

288. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38491/psn-pdf
     January 31, 2011 - This commentary discusses individual and systems factors that lead to diagnostic error and proposes … An AHRQ WebM&M perspective discussed cognitive biases that lead to diagnostic error.

289. Overdiagnosis in Prostate Cancer Screening Decision Models: A Contextual Review for the USPSTF (pdf file)
     www.uspreventiveservicestaskforce.org/home/getfilebytoken/KT7vaWK_JSDNNvEmUAjN8d
     May 01, 2018 - The modeling studies we discuss use the lead time approach; lead time is derived as an intermediate … The lead time approach to estimate overdiagnosis is also conceptually simple. … Using the lead time approach, models generate estimates of lead time and age at screen detection, couple … In all three models, lead time is an intermediate estimate made using the model and estimates of lead … PSA screening is superimposed to estimate lead time.

290. Improving Antibiotic Use is a Patient Safety Issue
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/implementing-stewardship-slides.pptx
     September 01, 2022 - Antibiotic Use – Ambulatory Care 5 Step 2: Establish an Antibiotic Stewardship Team6 6 Clinician lead … Interest in patient safety/quality improvement Diplomatic, collegial, communication skills Administrative lead … with practicewide consensus on treatment of common infectious disease syndrome Stewardship clinician lead … consistent, practicewide strategies for communicating with patients and families8-11 Stewardship clinician lead

291. Module 2: Obtaining Organizational Buy-in and Support | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes2.html
     August 01, 2022 - If a senior leader or the risk management director are not the designated CANDOR Implementation Team Lead … , they can support the CANDOR Implementation Team Lead by helping the team set goals, facilitating progress … The CANDOR Implementation Team Lead is the senior leader who is responsible for organization-wide implementation … The CANDOR Implementation Team and Team Lead can also ask the senior leaders and risk management personnel

292. Harm From Alarm Fatigue | PSNet
     psnet.ahrq.gov/web-mm/harm-alarm-fatigue
     February 14, 2018 - Yet excessive false alarms may lead to unintended harm. … Since one monitor watcher is responsible for watching as many as 40 patients' data, only one ECG lead … If the telemetry algorithm uses just one ECG lead for analysis, this can more easily be misinterpreted … the responsible physician, the correct action would have been to search for another ECG monitoring lead … For example, the resident and nurse could have checked the patient's full diagnostic standard 12-lead

293. Opioid prescribing for opioid-naive patients in emergency departments and other settings: characteristics of prescriptions and association with long-term use. | PSNet
     psnet.ahrq.gov/issue/opioid-prescribing-opioid-naive-patients-emergency-departments-and-other-settings
     August 29, 2018 - has shown that prescribing opioids to opioid-naïve patients at the time of hospital discharge may lead … prescribing in the emergency department more often comported with CDC guidelines and was less likely to lead

294. Defining, estimating, and communicating overdiagnosis in cancer screening. | PSNet
     psnet.ahrq.gov/issue/defining-estimating-and-communicating-overdiagnosis-cancer-screening
     October 13, 2018 - The associated overtreatment that results from overdiagnosis can lead to increased financial stress and … shown that breast cancer screening may identify lesions that are not clinically meaningful and may lead

295. Night-time communication at Stanford University Hospital: perceptions, reality and solutions. | PSNet
     psnet.ahrq.gov/issue/night-time-communication-stanford-university-hospital-perceptions-reality-and-solutions
     March 24, 2019 - Interruptions can lead to errors , particularly when providers are sleep deprived . … March 20, 2015 Did duty hour reform lead to better outcomes among the highest risk patients

296. What price must we pay for safety? Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared consumers. | PSNet
     psnet.ahrq.gov/issue/what-price-must-we-pay-safety-excessive-cost-epinephrine-auto-injectors-leads-error-prone-use
     September 14, 2016 - administration methods used to reduce device costs can introduce heightened potential for dosing errors and lead

297. Communication and Optimal Resolution (CANDOR) Toolkit Module 3: Preparing for Implementation: Change Readiness and Gap Analysis
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/module3-assessment-change-readiness-gap-analysis.pptx
     August 25, 2015 - For the change effort to be successful, a group must lead the change and work as a team to support the … Key characteristics of team members should include: authority to lead the change, leadership skills, … The Team Lead for each subgroup is responsible for overseeing the implementation of individual steps … for the disclosure communication process for the organization and Care for the Caregiver Lead, responsible … The CANDOR Implementation Team can help lead the development of this shared vision for the CANDOR process

298. Distracting communications in the operating theatre. | PSNet
     psnet.ahrq.gov/issue/distracting-communications-operating-theatre
     August 18, 2017 - communication to errors, the authors speculate that the large number of "case-irrelevant communications" could lead … April 10, 2019 Inadequate preoperative team briefings lead to more intraoperative adverse

299. Missed diagnoses of acute cardiac ischemia in the emergency department. | PSNet
     psnet.ahrq.gov/issue/missed-diagnoses-acute-cardiac-ischemia-emergency-department
     November 30, 2012 - Missed or delayed diagnosis of cardiovascular disease can lead to adverse patient outcomes . … 2018 WebM&M Cases Missing ECG and Missed Diagnosis Lead

300. Medical error—the third leading cause of death in the US. | PSNet
     psnet.ahrq.gov/issue/medical-error-third-leading-cause-death-us
     September 16, 2020 - 2025 The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead