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281. 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.

282. 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.

283. 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.

284. 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

285. 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

286. 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

287. 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

288. 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

289. 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

290. 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

291. 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

292. AHRQ Expands Its Repertoire to Eliminate Diagnostic Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/eliminate-diagnostic-errors.html
     August 01, 2022 - Regardless of the setting, diagnostic errors can derail proper care and may lead to severe injury or … All of AHRQ’s efforts in diagnostic safety – its lead role among Federal agencies, its research investments

293. 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

294. Redesigning Primary Health Care Teams for Population Health and Quality Improvement | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/delivery-initiative/redesigningprimaryhealthcareteams.html
     November 01, 2017 - For the first phase in implementation of a redesigned team, the quality improvement lead provided 30 … In addition to training, implementation included team coaching by the quality improvement lead. … To support implementation and address new workflow concerns as they arose, the quality improvement lead … By design, quality improvement leads chose provider champions at each practice site willing to lead and … It was important that a quality improvement lead was present to make senior-level decisions on changes

295. When we're all responsible for a patient's death, no one is. | PSNet
     psnet.ahrq.gov/issue/when-were-all-responsible-patients-death-no-one
     December 09, 2020 - 2020 Open Notes shines light on errors in patient medical records — will the new rule lead … April 20, 2022 Will prosecuting medical errors lead to a culture of silence?

296. Methods | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/clabsi-neonatal/nclabsi2.html
     January 01, 2013 - The Missouri Center for Patient Safety (MOCPS) was selected to lead this effort. … State Clinical Lead Calls and Face-to-Face Meetings.

297. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42588/psn-pdf
     September 18, 2013 - However, this process can lead to diagnostic error, as numerous cognitive biases can adversely affect … Pat Croskerry, the lead author of these articles, was interviewed by AHRQ WebM&M in 2010.

298. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46416/psn-pdf
     March 13, 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

299. Preventing-Cauti-Icu-Setting-Module 2-Speaker-Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-module_2-speaker-notes.docx
     September 01, 2015 - and think about this question for a few minutes: What did you notice in the case scenario that could lead … AHRQ Pub No. 15-0073-4-EF September 2015 SAY: You should have identified three issues that can lead … Not attaching the catheter to the leg can lead to urethral irritation. 3.

300. Title Page (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015124-selker-final-report-2008.pdf
     January 01, 2008 - Prehospital 12-lead ECG with ACI-TIPI and TPI Site Selection EMS agencies were selected … The target measures included: chest pain assessment, 12-lead ECG performance and interpretation, and … Figure 4. 12-Lead ECG performance feedback report Figure 5. … Logistic Regression was used to measure associations between having a 12-lead ECG and the variables … Factors associated with 12-Lead ECG performance Table 2a.