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341. A multi-hospital before–after observational study using a point-prevalence approach with an infusion safety intervention bundle to reduce intravenous medication administration errors. | PSNet
     psnet.ahrq.gov/issue/multi-hospital-after-observational-study-using-point-prevalence-approach-infusion-safety
     January 23, 2017 - rate and medication error rate per 100 medication administrations decreased, the intervention did not lead … May 16, 2018 The other opioid crisis: hospital shortages lead to patient pain, medical

342. Teamwork- Part 1: Divided We Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem Problem. | PSNet
     psnet.ahrq.gov/issue/teamwork-part-1-divided-we-fall-part-2-cursed-knowledge-building-culture-psychological-safety
     August 02, 2015 - care becomes more complex, more teams and subspecialists are involved in a patient's care, which may lead … October 3, 2017 Did duty hour reform lead to better outcomes among the highest risk patients

343. Evaluation of outcomes from a national patient-initiated second-opinion program. | PSNet
     psnet.ahrq.gov/issue/evaluation-outcomes-national-patient-initiated-second-opinion-program
     July 15, 2015 - Diagnostic errors can lead to delayed or incorrect treatments, resulting in serious patient harms. … April 8, 2018 Diagnostic errors that lead to inappropriate antimicrobial use.

344. AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/overviewhandouts4.html
     December 01, 2017 - Leadership agrees to identify a change team champion and establish a multidisciplinary change team to lead … Two team leaders may co-lead project activities; one is a nurse and the second can be from nursing or … who should attend the meeting, what their roles are, who is responsible for the reports, and who will lead

345. Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ptmgmt/summary.html
     July 01, 2018 - Improved behavior is expected to lead to better disease control which should, in turn, lead to better … better at managing their disease and allow sufficient time to assess if patients' changed behaviors lead

346. Complexity, Incidence, and Costs Related to Delayed Diagnosis of Venous Thromboembolism in Urban and Rural Primary and Urgent Care Settings | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/complexity-incidence-and-costs-related-delayed-diagnosis-venous
     September 01, 2024 - If not diagnosed and treated in time, VTE can lead to severe complications, prolonged hospital stays, … In the long run, this research could lead to new tools, guidelines, and policies that improve patient

347. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43695/psn-pdf
     August 02, 2015 - systems (which use an adjudication process rather than usual courts) will all play a larger role and lead … Formation of accountable care organizations may lead to reform in the liability system such that organizations

348. Tools for Sustainability: Premortem and Scorecard: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/sustainability/premortem-scorecard-slides.html
     February 01, 2017 - Slide 13: Preparing To Lead 2 In a postmortem, an autopsy is performed to learn why a patient died … Slide 14: Preparing To Lead 2 Identify potential barriers and vulnerabilities. … Slide 15: Preparing To Lead 2 The Premortem Exercise helps you– Imagine the project has failed

349. PowerPoint Presentation: Premortem for Sustainability
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_premortem.pptx
     December 01, 2017 - to the clinicians and those interested in the results, it doesn’t help the patient. 4 Preparing To Lead … premortem encourages you to imagine that the project has failed and brainstorm the reasons that could lead … the exercise individually, have team members share their responses with the team. 5 Preparing To Lead

350. Improving Care Transitions of Hospitalized Patients With the Pharmacy Integrated Transitions Program | Digital Healthcare Research
     digital.ahrq.gov/2020-year-review/research-summary/improving-care-transitions-hospitalized-patients-pharmacy-integrated-transitions-program
     January 01, 2020 - medical professionals at each facility is a significant issue throughout care transitions, which can lead … to medication-related problems, and complications that can lead to preventable hospital readmission.

351. Hospira Carpuject pre-filled cartridges—drug alert: products may contain more than the intended fill volume. | PSNet
     psnet.ahrq.gov/issue/hospira-carpuject-pre-filled-cartridges-drug-alert-products-may-contain-more-intended-fill
     August 05, 2020 - , 2012 Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead … Differences in strength expression on product labels of compounders and conventional manufacturers may lead

352. Understanding the Role of Health Care Facility Design in the Acquisition and Prevention of HAIs: Summary (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/haidesign-summary.pdf
     September 01, 2013 - agents can be brought into hospitals by colonized or infected hosts or other external sources and lead … Contact with contaminated surfaces can lead to transmission of pathogens, with health care workers … suboptimal maintenance of the built environment can increase the risk of transmission of pathogens and can lead … easy to merge discipline-specific perspectives through collaboration, but such open dialogue will lead

353. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866847/psn-pdf
     September 25, 2024 - The evidence-based approach is true when it comes to preventing errors and mistakes that can lead to … processes that reduce the probability of experiencing errors and catching errors that occur before they lead … culture in what they say and do is critical to ensuring that a zero harm goal doesn't potentially lead … that CEO left, those organizations lost those gains in a matter of months when the new CEO didn’t lead

354. National Content Series Facilitator’s Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/urine-culturing/when-to-order/role-play.html
     May 01, 2017 - After the role-play, lead a discussion with staff using the discussion questions and/or worksheet provided … Ask for volunteers to share their SBAR with the group and lead a discussion in a nonpunitive manner. … Ordering a urine culture will not help decipher between a CAUTI and asymptomatic bacteriuria and may lead … Ordering a urine culture will not help decipher between a CAUTI and asymptomatic bacteriuria and may lead

355. Context is Critical: Understanding When and Why Electronic Health Record-Related Safety Hazards Happen | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/context-critical-understanding-when-and-why-electronic-health-record-related
     January 01, 2023 - error through video review and systematically categorize the observed errors to understand what factors lead … Record-Related Safety Hazards Happen Funded Amount: $297,840 Does inadequate EHR design lead … new features and minor adjustments to the EHR over time—impacts the usability of the system and may lead … How small inconsistencies can lead to increased errors A second example found from the black box analysis

356. Spotlight
     psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
     January 01, 2024 - His 12-lead electrocardiogram (ECG) demonstrated normal sinus rhythm and right bundle branch block (RBBB … Overview 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 … Take Home Points 27 Take-Home Points 28 Failure to recognize lab values affected by hemolysis can lead

357. Screening for Overweight in Children and Adolescents: Where Is the Evidence? (pdf file)
     www.uspreventiveservicestaskforce.org/home/getfilebytoken/7K93Ldpe86aLuGS65CPKYp
     July 01, 2005 - been identified correctly); and whether intermediate outcomes such as weight loss or stabilization lead … Arrow 4: Do interventions lead to improved intermediate outcomes, including behavioral, physiologic or … Arrow 5: Do interventions (behavioral counseling, pharmacotherapy, surgery) lead to improved health outcomes … Arrow 4: Do interventions lead to improved intermediate outcomes, including behavioral, physiologic or … Rivara FP, Whitaker R, Sherman PM, Cuttler L Influencing the childhood behaviors that lead to obesity

358. mHealth for Diabetes (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/tnd-0855-170515.pdf
     April 28, 2017 - rslt=&age_v=&gndr=&cond=diabetes&intr=NOT+drug&titles=&outc=management+OR+control+OR+prevent&spons=&lead … rslt=&age_v=&gndr=&cond=diabetes&intr=NOT+drug&titles=&outc=management+OR+control+OR+prevent&spons=&lead … rslt=&age_v=&gndr=&cond=diabetes&intr=NOT+drug&titles=&outc=management+OR+control+OR+prevent&spons=&lead … rslt=&age_v=&gndr=&cond=diabetes&intr=NOT+drug&titles=&outc=management+OR+control+OR+prevent&spons=&lead … rslt=&age_v=&gndr=&cond=diabetes&intr=NOT+drug&titles=&outc=management+OR+control+OR+prevent&spons=&lead

359. mHealth for Diabetes (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/pdf/TND-0855-170515.pdf
     April 28, 2017 - rslt=&age_v=&gndr=&cond=diabetes&intr=NOT+drug&titles=&outc=management+OR+control+OR+prevent&spons=&lead … rslt=&age_v=&gndr=&cond=diabetes&intr=NOT+drug&titles=&outc=management+OR+control+OR+prevent&spons=&lead … rslt=&age_v=&gndr=&cond=diabetes&intr=NOT+drug&titles=&outc=management+OR+control+OR+prevent&spons=&lead … rslt=&age_v=&gndr=&cond=diabetes&intr=NOT+drug&titles=&outc=management+OR+control+OR+prevent&spons=&lead … rslt=&age_v=&gndr=&cond=diabetes&intr=NOT+drug&titles=&outc=management+OR+control+OR+prevent&spons=&lead

360. Technical Brief Summary - Impact of Community Health Worker Certification on Workforce and Service Delivery for Asthma and Other Selected Chronic Diseases (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/technical-brief-34-health-worker-certification-summary.pdf
     March 01, 2020 - Funding and Reimbursement May lead to sustainable funding, employment opportunities, and reimbursement … May not lead to better pay or employment opportunities. … Could lead to “de facto” mandatory certification, if certified CHWs are favored over those who have