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  1. Survey results: community liaison programs to decrease hospital readmissions. | PSNet

    psnet.ahrq.gov/issue/survey-results-community-liaison-programs-decrease-hospital-readmissions
    June 10, 2018 - Resources From the Same Author(s) Drawn curtains, muted alarms, and diverted attention lead … June 10, 2018 Administering a saline flush "site unseen" can lead to a wrong route error

  2. Measures of Impact for BLUES project (pdf file)

    digital.ahrq.gov/sites/default/files/docs/resource/Karen_Fox_IQHIT_Q4_Measures_of_Impact_for_BLUES_Project.pdf
    June 16, 2021 - Measures of Impact for BLUES project Measures of Impact for BLUES project Lead Agency: Delta Health … Measures of Impact for BLUES project Lead Agency: Delta Health Alliance

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72689/psn-pdf
    January 29, 2021 - salt and sodium bicarbonate mouthwash and pain control.4 A timely diagnosis of oral mucositis will lead … to Horwtiz et al.5 Unfortunately, blood cultures are low in yield6 and a false positive can often lead … radiologic tests.”9 The reflexive ordering of tests without a proper in-person bedside assessment may lead … to more patient handoffs.11 Frequent and poor handoffs can lead to more cross-cover questions, calls … is still hope that creating a better culture of safety will hopefully encourage more teamwork and lead

  4. Why are medical errors still a leading cause of death? | PSNet

    psnet.ahrq.gov/issue/why-are-medical-errors-still-leading-cause-death
    September 13, 2017 - Newspaper/Magazine Article Why are medical errors still a leading cause of death? Citation Text: Why are medical errors still a leading cause of death? Headley M. Copy Citation Save Save to your library Print Download PDF Share Facebook …

  5. Selection of incorrect medication pump leads to chemotherapy overdose. | PSNet

    psnet.ahrq.gov/issue/selection-incorrect-medication-pump-leads-chemotherapy-overdose
    September 09, 2015 - Newspaper/Magazine Article Selection of incorrect medication pump leads to chemotherapy overdose. Citation Text: Selection of incorrect medication pump leads to chemotherapy overdose. ISMP Canada. August 26, 2015;15:1-4. Copy Citation Save Save to your library …

  6. Leading Health Care Transformation: A Primer for Clinical Leaders. | PSNet

    psnet.ahrq.gov/issue/leading-health-care-transformation-primer-clinical-leaders
    April 12, 2017 - Book/Report Leading Health Care Transformation: A Primer for Clinical Leaders. Citation Text: Leading Health Care Transformation: A Primer for Clinical Leaders. Joshi M, Erb N, Zhang S, Sikka R. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498700184. Copy Citation Save …

  7. Effective Health Care (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/TND_0332_07-29-2010.pdf
    January 01, 2010 - (s): 0283 Document Completion Date: 11-16-10 2 (active surveillance vs. active treatment) lead … Does use of the PCA3 assay lead to improved health outcomes when compared with or in addition to use … Do changes in screening and management for prostate cancer resulting from use of PCA3 assays lead to

  8. Electrocardiogram Results: ***READ ME*** | PSNet

    psnet.ahrq.gov/web-mm/electrocardiogram-results-read-me
    May 01, 2019 - Delays in making this diagnosis can lead to significant adverse outcomes for patients. … This can lead to an erroneous diagnosis of acute myocardial infarction ( Table ) or other clinically … Subarachnoid hemorrhage • Metabolic disturbances, such as hyperkalemia • Cardiomyopathy • Lead … 2019 WebM&M Cases Missing ECG and Missed Diagnosis Lead

  9. Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community. | PSNet

    psnet.ahrq.gov/issue/reduce-readmissions-pharmacy-programs-focus-transitions-hospital-community
    September 26, 2016 - Interruptions lead to errors and unfinished…wait, what was I doing? … 8, 2016 Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead

  10. A mislabeling event with batched drugs: the unintended consequences of practice changes. | PSNet

    psnet.ahrq.gov/issue/mislabeling-event-batched-drugs-unintended-consequences-practice-changes
    May 07, 2014 - June 10, 2018 Administering a saline flush "site unseen" can lead to a wrong route error … 10, 2018 Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead

  11. Program Evaluation (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_8-program-evaluation-speaker-notes.pdf
    July 01, 2023 - patient safety culture becoming better established and improving over time Collectively, these will lead … lead to reductions in adverse events – as shown in the impact column. 18 Hospital AIM Team

  12. Program Evaluation (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_8-program-evaluation-speaker-notes.pdf
    July 01, 2023 - patient safety culture becoming better established and improving over time Collectively, these will lead … lead to reductions in adverse events – as shown in the impact column. 18 Hospital AIM Team

  13. Introduction to the SPPC-II Teamwork Toolkit for Obstetric Hemorrhage - PowerPoint Presentation

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_1-introduction.pptx
    July 01, 2023 - workshop Teamwork basics Teamwork tool specifics Implementation guidance Organize frontline participation Lead … We will help you organize frontline participation and teach you how to lead the facilitation sessions … Ultimately, it is your responsibility as a Hospital AIM Team Lead to enable and encourage your frontline

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33725/psn-pdf
    February 01, 2012 - be taken in GME to improve patient safety.(3,4) Most recently, ACGME, largely following the IOM's lead … In other words, inadequate supervision may lead to unintended harm to patients in the present, but excessive … supervision may lead to unintended harm to patients in the future by limiting the amount of independent … compliance with practice guidelines, decrease complications and mortality rates in the operating room, and lead

  15. NASHP Environmental Scan 3-1 to TR v2.xls (pdf file)

    hcup-us.ahrq.gov/reports/race/50StateScan04_26forweb.pdf
    December 01, 2010 - Accurate as of 2/3/11) Topics Focus on Disparities in Health Status, Health Care or Both Impetus Lead … Accurate as of 2/3/11) Topics Focus on Disparities in Health Status, Health Care or Both Impetus Lead … Diseases Section, Vital Records (birth and death registries), Linked File of Life and Infant Births, Lead … Poisoning and Prevention Control Program Blood Lead Level Data Geographic (State) Black or African … Census Bureau, Vital Statistics System, BRFSS, Blood Lead Surveillance System, Cancer Registry, VT

  16. Drug shortages continue to compromise patient care. | PSNet

    psnet.ahrq.gov/issue/drug-shortages-continue-compromise-patient-care
    February 24, 2016 - , 2018 Smart pump custom concentrations without hard "low concentration" alerts can lead … June 27, 2018 The other opioid crisis: hospital shortages lead to patient pain, medical

  17. Kadcyla (ado-trastuzumab emtansine): drug safety communication—potential medication errors resulting from name confusion. | PSNet

    psnet.ahrq.gov/issue/kadcyla-ado-trastuzumab-emtansine-drug-safety-communication-potential-medication-errors
    October 09, 2013 - , 2013 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

  18. Survey results: smart pump data analytics pump metrics that should be monitored to improve safety. | PSNet

    psnet.ahrq.gov/issue/survey-results-smart-pump-data-analytics-pump-metrics-should-be-monitored-improve-safety
    August 08, 2018 - , 2018 Smart pump custom concentrations without hard "low concentration" alerts can lead … , 2018 Smart pump custom concentrations without hard "low concentration" alerts can lead

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49556/psn-pdf
    March 01, 2008 - What appears to be a simple and straightforward order can lead to a variety of breakdowns in the medication … administration process and potentially lead to patient harm, as it did in this case. … For example, oral medications for diabetes (which can lead to hypoglycemia if patients are not eating … Take-Home Points Temporary hold orders can lead to multiple errors and complications in the medication … Hold orders can lead to problems with medication prescribing, transcription, or order entry.

  20. Program Evaluation - PowerPoint Presentation

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_8_program-evaluation.pptx
    July 01, 2023 - patient safety culture becoming better established and improving over time Collectively, these will lead … lead to reductions in adverse events – as shown in the impact column. 17 Evaluation Data Collection
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