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121. When diagnostic testing leads to harm: a new outcomes-based approach for laboratory medicine. | PSNet
     psnet.ahrq.gov/issue/when-diagnostic-testing-leads-harm-new-outcomes-based-approach-laboratory-medicine
     September 12, 2018 - Commentary When diagnostic testing leads to harm: a new outcomes-based approach for … When diagnostic testing leads to harm: a new outcomes-based approach for laboratory medicine. … When diagnostic testing leads to harm: a new outcomes-based approach for laboratory medicine.

122. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40055/psn-pdf
     December 01, 2010 - Parkland knee surgery done by doctor in training leads to amputation, questions. … https://psnet.ahrq.gov/issue/parkland-knee-surgery-done-doctor-training-leads-amputation-questions This … https://psnet.ahrq.gov/issue/parkland-knee-surgery-done-doctor-training-leads-amputation-questions https

123. Implementing the SPPC-II Teamwork Toolkit (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_7-implementation-speaker-notes.pdf
     July 01, 2023 - tactics and planning for the SPPC‐II Teamwork Toolkit implementation. 1 Hospital AIM Team Leads … providing your organizational leadership with an overview of your plan. 2 Hospital AIM Team Leads … We will now be working on the last four steps. 4 Hospital AIM Team Leads SPPC‐II ✓ Step … 10 Hospital AIM Team Leads SPPC‐II Step 3A: Establish a Roll‐out Plan with timeframe Key … 21 Hospital AIM Team Leads SPPC‐II Step 6.

124. Procedure Manual Section 7. Formulation of Task Force Recommendations | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual/procedure-manual-section-7-formulation-task-force-recommendations
     March 06, 2025 - After full consideration and decision on both certainty and magnitude of net benefit, the topic leads … , the leads identify any grade changes and discuss the rationale for proposed grade change. … The leads refine the draft recommendation with final language before it is released for public comment … At that point, any new evidence is reviewed by the topic leads with help from AHRQ and the appropriate … The topic leads present their motion and any important new evidence to the full Task Force (most often

125. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39825/psn-pdf
     June 10, 2018 - Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error. … https://psnet.ahrq.gov/issue/electronic-prescribing-vulnerabilities-height-and-weight-mix-leads-dosing-error … https://psnet.ahrq.gov/issue/electronic-prescribing-vulnerabilities-height-and-weight-mix-leads-dosing-error

126. 165-Cusp-Monthly-Meeting-Agenda (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/165-cusp-monthly-meeting-agenda.docx
     August 21, 2024 - Agenda Overview: CUSP Champion or designated team leads summarizes the agenda. … State of Our Safety Union: CUSP Champion or designated team leads/guest speakers may share dashboard … Status of Safety Efforts: CUSP Champion or designated team leads share status of current safety projects

127. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44363/psn-pdf
     May 05, 2018 - Selection of incorrect medication pump leads to chemotherapy overdose. May 5, 2018 ISMP Canada. … https://psnet.ahrq.gov/issue/selection-incorrect-medication-pump-leads-chemotherapy-overdose Checklists … https://psnet.ahrq.gov/issue/selection-incorrect-medication-pump-leads-chemotherapy-overdose https://

128. Procedure Manual Section 7. Formulation of Task Force Recommendations | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/procedure-manual/procedure-manual-section-7-formulation-task-force-recommendations
     April 05, 2021 - After full consideration and decision on both certainty and magnitude of net benefit, the topic leads … , the leads identify any grade changes and discuss the rationale for proposed grade change. … The leads refine the draft recommendation with final language before it is released for public comment … At that point, any new evidence is reviewed by the topic leads with help from AHRQ and the appropriate … The topic leads present their motion and any important new evidence to the full Task Force (most often

129. PSNet Curated Library (pdf file)
     psnet.ahrq.gov/print/pdf/node/866843
     January 01, 2024 - Web M&Ms Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. … 866843 https://psnet.ahrq.gov/primer/falls https://psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes … Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. … preventing-falls-through-patient-and-family-engagement-create-customized-prevention https://psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes

130. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44183/psn-pdf
     November 03, 2015 - The absence of a drug–disease interaction alert leads to a child's death. … https://psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death The disabling … https://psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death https://psnet.ahrq.gov

131. Mutual Support: Obstetric Hemorrhage - PowerPoint Presentation
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_5-mutual-support.pptx
     July 01, 2023 - No. 23-0046 July 2023 Hospital AIM Team Leads SPPC-II SCRIPT Welcome to Module 5 of the SPPC-II Teamwork … 11 Hospital AIM Team Leads SPPC-II SCRIPT Break into groups of two or three individuals. … Sonentag, obstetrician Hospital AIM Team Leads SPPC-II SCRIPT Dr. … Sonentag, obstetrician Hospital AIM Team Leads SPPC-II SCRIPT Dr. … Sonentag, obstetrician Hospital AIM Team Leads SPPC-II SCRIPT At the end, Dr.

132. Mutual Support: Obstetric Hemorrhage - PowerPoint Presentation
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_5-mutual-support.pptx
     July 01, 2023 - No. 23-0046 July 2023 Hospital AIM Team Leads SPPC-II SCRIPT Welcome to Module 5 of the SPPC-II Teamwork … 11 Hospital AIM Team Leads SPPC-II SCRIPT Break into groups of two or three individuals. … Sonentag, obstetrician Hospital AIM Team Leads SPPC-II SCRIPT Dr. … Sonentag, obstetrician Hospital AIM Team Leads SPPC-II SCRIPT Dr. … Sonentag, obstetrician Hospital AIM Team Leads SPPC-II SCRIPT At the end, Dr.

133. Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care-2/index.html
     July 01, 2023 - Tier 2: AIM Team Leads The SPPC-II Teamwork Toolkit recognizes that individuals responsible for making … These individuals, termed “AIM Team Leads,” were identified by the State AIM leadership in their State … As leaders who “champion” these initiatives, AIM Team Leads may benefit from more conceptual understanding … , emodules for education of frontline clinicians, PowerPoint slide sets for AIM Team Leads, and a guide … Frontline clinicians and AIM Team Leads can review these individually, or they can be presented as part

134. Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage | Agency for Healthcare Research and Quality
     pcmh.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care-2/index.html
     July 01, 2023 - Tier 2: AIM Team Leads The SPPC-II Teamwork Toolkit recognizes that individuals responsible for making … These individuals, termed “AIM Team Leads,” were identified by the State AIM leadership in their State … As leaders who “champion” these initiatives, AIM Team Leads may benefit from more conceptual understanding … , emodules for education of frontline clinicians, PowerPoint slide sets for AIM Team Leads, and a guide … Frontline clinicians and AIM Team Leads can review these individually, or they can be presented as part

135. The problem of integrating behavioral health in the medical home and the questions it leads to | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency
     digital.ahrq.gov/health-it-tools-and-resources/health-it-bibliography/medical-home/problem-integrating-behavioral
     April 26, 2021 - The problem of integrating behavioral health in the medical home and the questions it leads to …   4-12 Link:  The problem of integrating behavioral health in the medical home and the questions it leads

136. Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Mazur (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/3-unc-webcast-mazur.pdf
     January 08, 2020 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture … U N C H E A L T H C A R E Implementation of an Event Reporting and Learning System Leads … rewards & recognition, • Lead by example Implementation of an Event Reporting and Learning System Leads

137. Supporting Clinical Staff Who Prescribe Opioids to Older Adults: Providing Targeted Educational Sessions to Meet Needs Case Study (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-case-study-prescribe-opioids.pdf
     December 15, 2023 - The QI-leads conducted an internal survey of prescribers and nurses to evaluate the process used to … DOs, 16 NPs/PAs, 27 LPNs, 14 RNs1 ▶ Number of patients: 24,000 ▶ Quality Improvement team: The QI leads … Afer the pilot period, the QI leads conducted a post-implementation survey to solicit feedback from … One of the QI leads worked with nurses to develop and present several education activities at two Mayo … Afer implementing the opioid misuse screener, the QI leads developed a survey to obtain feedback on

138. Opportunity for Public Comment | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/public-comments-and-nominations/opportunity-for-public-comment
     March 06, 2025 - 2025 11:59 PM EST Research Plans A small group of USPSTF members, called topic leads … The USPSTF topic leads, with the assistance of the EPC researchers, review all of the comments received … After the meeting, the topic leads write a full draft Recommendation Statement that includes the specific … The USPSTF topic leads review all of the comments received and revise the draft Recommendation Statement

139. Appendix M. Example of a Nurse-Driven Protocol for Catheter Removal | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/impl-guide/implementation-guide-appendix-m.html
     October 01, 2020 - Leads to; Observe Choice 2: Patient voids within 6 hours but has symptoms of abdominal fullness or … Leads to: Bladder scan. If volume <300 cc, observe. … Leads to: Bladder scan. If volume <300 cc, observe.

140. Communication: Obstetric Hemorrhage - PowerPoint Presentation
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3_communication.pptx
     July 01, 2023 - No. 23-0046 July 2023 Hospital AIM Team Leads SPPC-II SCRIPT Welcome to Module 3 of the SPPC-II Teamwork … Hospital AIM Team Leads SPPC-II SCRIPT One critical point to discuss is the appropriateness of using … 15 Hospital AIM Team Leads SPPC-II Discussion: Who was the sender? Who was the receiver? … Approximate time: 10 min 23 Hospital AIM Team Leads SPPC-II SCRIPT Let’s do an activity. … 27 Hospital AIM Team Leads SPPC-II SCRIPT Let's review how to properly use the SBAR technique.