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2321. Utilization of the Seniors Falls Investigation Methodology to identify system-wide causes of falls in community-dwelling seniors. | PSNet
      psnet.ahrq.gov/issue/utilization-seniors-falls-investigation-methodology-identify-system-wide-causes-falls
      November 21, 2014 - Study Utilization of the Seniors Falls Investigation Methodology to identify system-wide causes of falls in community-dwelling seniors. Citation Text: Zecevic AA, Salmoni AW, Lewko JH, et al. Utilization of the Seniors Falls Investigation Methodology to identify system-wide causes of f…

2322. Interventional procedures outside of the operating room: results from the National Anesthesia Clinical Outcomes Registry. | PSNet
      psnet.ahrq.gov/issue/interventional-procedures-outside-operating-room-results-national-anesthesia-clinical
      March 06, 2019 - Study Emerging Classic Interventional procedures outside of the operating room: results from the National Anesthesia Clinical Outcomes Registry. Citation Text: Chang B, Kaye AD, Diaz JH, et al. Interventional Procedures Outside of the Operating Room: Results Fro…

2323. Clinical pharmacy interventions in paediatric electronic prescriptions. | PSNet
      psnet.ahrq.gov/issue/clinical-pharmacy-interventions-paediatric-electronic-prescriptions
      April 14, 2010 - Study Clinical pharmacy interventions in paediatric electronic prescriptions. Citation Text: Maat B, San Au Y, Bollen CW, et al. Clinical pharmacy interventions in paediatric electronic prescriptions. Arch Dis Child. 2013;98(3):222-7. doi:10.1136/archdischild-2012-302817. Copy Citatio…

2324. Action Planning for the SOPS Surveys-Introducing SOPS (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-gray-sops-action-planning-tool.pdf
      June 02, 2025 - Action Planning for the SOPS Surveys-Introducing SOPS 10 Introducing the SOPS Action Planning Tool Laura Gray, MPH Senior Study Director, User Network for the AHRQ Surveys on Patient Safety Culture (SOPS) Westat 11 AHRQ Surveys on Patient Safety Culture Surveys of clinicians and staff about the extent to w…

2325. 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 - Study Classic Missed diagnoses of acute cardiac ischemia in the emergency department. Citation Text: Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342(16):1163-1170. doi:10.…

2326. Health Information Exchange Streamlines Communication Between Poison Control Centers and Emergency Departments | Digital Healthcare Research
      digital.ahrq.gov/2019-year-review/research-summary/health-information-exchange-streamlines-communication-between
      January 01, 2019 - Health Information Exchange Streamlines Communication Between Poison Control Centers and Emergency Departments The research team created the first HIE capability between a poison control center (PCC) and ED to reduce errors, improve decision making, and improve continuity of care for poisonings, including drug ove…

2327. Afraid in the hospital: parental concern for errors during a child's hospitalization. | PSNet
      psnet.ahrq.gov/issue/afraid-hospital-parental-concern-errors-during-childs-hospitalization
      April 21, 2011 - Study Classic Afraid in the hospital: parental concern for errors during a child's hospitalization. Citation Text: Tarini BA, Lozano P, Christakis DA. Afraid in the hospital: parental concern for errors during a child's hospitalization. J Hosp Med. 2009;41(9):…

2328. 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 - Complexity, Incidence, and Costs Related to Delayed Diagnosis of Venous Thromboembolism in Urban and Rural Primary and Urgent Care Settings Project Description Using a mixed method approach including machine learning (ML) to improve early detection of venous thromboembolism (VT…

2329. EMS Based TIPI-IS Cardiac Care QI-Error Reduction System | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/ems-based-tipi-cardiac-care-qi-error-reduction-system
      January 01, 2023 - EMS Based TIPI-IS Cardiac Care QI-Error Reduction System Project Final Report ( PDF , 1.05 MB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ…

2330. TeamSTEPPS® Helps St. Louis Hospital Keep C-Section Rate Low | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsroom/case-studies/201904.html
      June 01, 2019 - TeamSTEPPS® Helps St. Louis Hospital Keep C-Section Rate Low Search All Impact Case Studies June 2019 Staff at SSM Health St. Mary's Hospital in St. Louis used AHRQ’s TeamSTEPPS training to improve their teamwork and communication, helping them to reduce the Cesarean section (C-section) rate for low-risk,…

2331. Transforming healthcare: a safety imperative. | PSNet
      psnet.ahrq.gov/issue/transforming-healthcare-safety-imperative
      June 26, 2019 - Commentary Classic Transforming healthcare: a safety imperative. Citation Text: Leape L, Berwick D, Clancy C, et al. Transforming healthcare: a safety imperative. Qual Saf Health Care. 2009;18(6):424-8. doi:10.1136/qshc.2009.036954. Copy Citation Format: …

2332. Debriefing in the emergency department after clinical events: a practical guide. | PSNet
      psnet.ahrq.gov/issue/debriefing-emergency-department-after-clinical-events-practical-guide
      November 16, 2022 - Commentary Debriefing in the emergency department after clinical events: a practical guide. Citation Text: Kessler DO, Cheng A, Mullan PC. Debriefing in the Emergency Department After Clinical Events: A Practical Guide. Ann Emerg Med. 2015;65(6):690-698. doi:10.1016/j.annemergmed.2014.10…

2333. Appendix-B-Cdspain-Practice-Readiness-Assessment (doc file)
      digital.ahrq.gov/sites/default/files/docs/citation/appendix-b-cdspain-practice-readiness-assessment.docx
      August 12, 2024 - Appendix B: Practice Readiness Assessment Determining your practice’s readiness to implement the clinician and patient facing Tapering And Patient Reported Outcomes for Chronic Pain Management (TAPR-CPM) application (app) is an important first step to beginning any project. Use the checklist below to evaluate your prac…

2334. Diagnostic delays in infectious diseases. | PSNet
      psnet.ahrq.gov/issue/diagnostic-delays-infectious-diseases
      December 15, 2021 - Study Diagnostic delays in infectious diseases. Citation Text: Suneja M, Beekmann SE, Dhaliwal G, et al. Diagnostic delays in infectious diseases. Diagnosis (Berl). 2022;9(3):332-339. doi:10.1515/dx-2021-0092. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML E…

2335. Misdiagnosis, mistreatment, and harm - when medical care ignores social forces. | PSNet
      psnet.ahrq.gov/issue/misdiagnosis-mistreatment-and-harm-when-medical-care-ignores-social-forces
      November 16, 2022 - Commentary Emerging Classic Misdiagnosis, mistreatment, and harm - when medical care ignores social forces. Citation Text: Holmes SM, Hansen H, Jenks A, et al. Misdiagnosis, mistreatment, and harm - when medical care ignores social forces. N Engl J Med. 2020;382…

2336. 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 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Handouts: Overview of On-Time (continued) Implementation Steps and Timeline Implementation Steps Estimated Duration / Time 1. Verify Nursing Home Readiness Leadership agrees to identify a change team champion and e…

2337. 2-Overview-Guide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/2-overview-guide.docx
      June 01, 2023 - Program Overview This guide provides a high-level overview of the entire Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Surgical Care and Recovery (ISCR) and toolkit. In addition to this guide, consider reviewing the ISCR overview presentation and facilitator guide to learn about ISCR…

2338. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.37_slideshow.ppt
      November 01, 2003 - Spotlight Case [MONTH] 2003 Spotlight Case November 2003 The Missing Suction Tip Source and Credits This presentation is based on the Nov. 2003 AHRQ WebM&M Spotlight Case in Surgery See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Eric J. Thomas, MD,…

2339. Summary | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ptmgmt/summary.html
      July 01, 2018 - Patient Self-Management Support Programs: An Evaluation Summary Previous Page Next Page Table of Contents Patient Self-Management Support Programs: An Evaluation Acknowledgments Introduction and Purpose Summary Background Methodology Design Options for a Self-Management Support Program …

2340. Introducing the CAHPS Child Hospital Survey_Transcript (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20150122/introducing-cahps-child-hospital-survey-transcript.pdf
      January 01, 2015 - Mark Schuster and he leads the CHIPRA -- I’m going to get the name wrong, Mark, so I’m going to allow … And the item that leads to is -- so if they say yes to the screener, then they answer, “How often did … So I have a wonderful nurse leader and patient-family experience that leads these efforts along with … My department really leads the coaching efforts.