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  1. Screen flashes and pop-up reminders: 'alert fatigue' spreads through medicine. | PSNet

    psnet.ahrq.gov/issue/screen-flashes-and-pop-reminders-alert-fatigue-spreads-through-medicine
    August 05, 2015 - December 14, 2022 Leaving a discontinued FentaNYL infusion attached to the patient leads

  2. Preventing high-alert medication errors in hospital patients. | PSNet

    psnet.ahrq.gov/issue/preventing-high-alert-medication-errors-hospital-patients
    November 18, 2015 - September 27, 2016 The absence of a drug–disease interaction alert leads to a child's

  3. Preventing diagnostic errors in primary care. | PSNet

    psnet.ahrq.gov/issue/preventing-diagnostic-errors-primary-care
    July 02, 2014 - April 3, 2018 When diagnostic testing leads to harm: a new outcomes-based approach for

  4. Quality indicators to detect pre-analytical errors in laboratory testing. | PSNet

    psnet.ahrq.gov/issue/quality-indicators-detect-pre-analytical-errors-laboratory-testing
    December 21, 2016 - October 9, 2013 When diagnostic testing leads to harm: a new outcomes-based approach

  5. Seattle pilot’s misdiagnosis highlights challenges around coronavirus testing. | PSNet

    psnet.ahrq.gov/issue/seattle-pilots-misdiagnosis-highlights-challenges-around-coronavirus-testing
    March 21, 2007 - August 5, 2020 Fear of Covid-19 leads other patients to decline critical treatment.

  6. EHRs in the ER: as doctors adapt, concerns emerge about medical errors. | PSNet

    psnet.ahrq.gov/issue/ehrs-er-doctors-adapt-concerns-emerge-about-medical-errors
    September 01, 2016 - November 23, 2016 WebM&M Cases Lapse in Antibiotics Leads

  7. The adoption of electronic medical record technology in order to prevent medical errors: a matter for American public policy. | PSNet

    psnet.ahrq.gov/issue/adoption-electronic-medical-record-technology-order-prevent-medical-errors-matter-american
    March 07, 2018 - August 8, 2018 Unprofessional Behavior Leads to Complications.

  8. Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient. | PSNet

    psnet.ahrq.gov/issue/taking-charge-your-healthcare-your-path-being-empowered-patient
    May 24, 2017 - Cases Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49729/psn-pdf
    April 01, 2015 - Dissecting the Presentation April 1, 2015 Suat-Ooi SB. Dissecting the Presentation. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/dissecting-presentation Case Objectives Define aortic dissection. Describe the epidemiology of acute aortic dissection. State the common and uncommon presentation of acute aor…

  10. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest | PSNet

    psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
    February 01, 2023 - SPOTLIGHT CASE When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Citation Text: Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.…

  11. Module 6: Sustainability: Facilitator Notes | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module6/mod6-facguide.html
    March 01, 2017 - Module 6: Sustainability: Facilitator Notes AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Slide 1: Module 6: Sustainability Say: The Sustainability module of this toolkit helps an organization maintain and sustain a process that has worked well. Slide 2: Objectives Say: In this module we wi…

  12. Developing Evidence-Based, User-Centered Design and Implementation Guidelines to Improve Health Information Technology Usability | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/developing-evidence-based-user-centered-design-and-implementation-guidelines
    January 01, 2023 - Developing Evidence-Based, User-Centered Design and Implementation Guidelines to Improve Health Information Technology Usability Project Final Report ( PDF , 283.3 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are respons…

  13. Engaging the Nurse, Physician, Patient/Family, CUSP- Learn From Defects | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cauti-tools/archived-webinars/engaging-nurse-physician-patient-slides.html
    August 01, 2018 - Nephrologist Surgeons Urologists Pareto Principle Image: Diagram showing that 20% effort leads

  14. Hiding in Plain Sight | PSNet

    psnet.ahrq.gov/web-mm/hiding-plain-sight
    April 24, 2019 - June 1, 2019 WebM&M Cases Lapse in Antibiotics Leads

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49403/psn-pdf
    June 01, 2003 - Perforation leads to longer hospital stays and delayed complications such as bowel obstruction.

  16. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps | PSNet

    psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
    April 24, 2018 - October 27, 2022 WebM&M Cases Saline Flush Leads

  17. Screening for Chronic Obstructive Pulmonary Disease (pdf file)

    www.uspreventiveservicestaskforce.org/home/getfilebytoken/CFNn2TBR6jtaNA87ER_Bop
    May 01, 2022 - Screening for Chronic Obstructive Pulmonary Disease 1 www.uspreventiveservicestaskforce.org Clinician Summary of USPSTF Recommendation Screening for Chronic Obstructive Pulmonary Disease May 2022 The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians s…

  18. Filespecifications Nis 2006 Hospital

    hcup-us.ahrq.gov/db/nation/nis/tools/stats/FileSpecifications_NIS_2006_Hospital.TXT
    January 01, 2006 - Data Set Name: NIS_2006_HOSPITAL Number of Observations: 1045 Total Record Length: 185 Total Number of Data Elements: 25 Columns Description ======= =========== 1- 3 Database name 5- 8 Discharge year of data 10- 25 File name 27- 29 Data element number 31- 59 Data element name 61-…

  19. Filespecifications Nis 2005 Hospital

    hcup-us.ahrq.gov/db/nation/nis/tools/stats/FileSpecifications_NIS_2005_Hospital.TXT
    January 01, 2005 - Data Set Name: NIS_2005_HOSPITAL Number of Observations: 1054 Total Record Length: 185 Total Number of Data Elements: 25 Columns Description: ======= ============ 1- 3 Database name 5- 8 Discharge year of data 10- 25 File name 27- 29 Data element number 31- 59 Data element name 6…

  20. Nis 2000 Hospital

    hcup-us.ahrq.gov/db/nation/nis/tools/stats/NIS_2000_HOSPITAL.TXT
    January 01, 2000 - Data Set Name: NIS_2000_HOSPITAL Number of Observations: 994 Total Record Length: 183 Total Number of Variables: 24 Columns Description: ======= ============ 1- 3 Database name 5- 8 Discharge year of data 10- 25 File name 27- 29 Variable number 31- 49 Variable name 5…
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