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2421. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. | PSNet
      psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
      September 27, 2023 - The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. Citation Text: Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depa…

2422. 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 - Tools for Sustainability: Premortem and Scorecard: Slide Presentation AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients Tools for Sustainability: Premortem and Scorecard Slide 2: Learning Objectives After this session, you will…

2423. 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 - PowerPoint Presentation: Premortem for Sustainability Sustainability and the Premortem Tool AHRQ Safety Program for Surgery Sustainability AHRQ Pub. No. 16(18)-0004-15-EF December 2017 AHRQ Safety Program for Surgery -- Sustainability SAY: This module will cover Sustainability and the Premortem Tool. Projects can fa…

2424. Errors in Paramedic Endotracheal Intubation (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/2006Wang_051611comp.pdf
      January 01, 2006 - Errors in Paramedic Endotracheal Intubation Errors in Paramedic Endotracheal Intubation Henry E. Wang, MD, MPH Assistant Professor Department of Emergency Medicine University of Pittsburgh School of Medicine University of Pittsburgh School of Medicine - Department of Emergency Medicine Disclosures  AHRQ Cli…

2425. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37165/psn-pdf
      May 02, 2018 - Lack of standard dosing methods contributes to IV errors. May 2, 2018 ISMP Medication Safety Alert! Acute care edition. August 23, 2007, https://psnet.ahrq.gov/issue/lack-standard-dosing-methods-contributes-iv-errors This article discusses the myriad dosing methods that can lead to errors in administering intraveno…

2426. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42410/psn-pdf
      July 10, 2013 - Doctors perform thousands of unnecessary surgeries. July 10, 2013 Eisler P; Hansen B. https://psnet.ahrq.gov/issue/doctors-perform-thousands-unnecessary-surgeries This newspaper article explains how unnecessary surgeries may lead to patient harm and how shared decision-making may prevent such procedures. https://…

2427. New Models of Primary Care Workforce - Case Example #5: WellMed (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_5.pdf
      October 01, 2016 - The clinic manager leads these meetings in a round table-discussion format.

2428. Sustainability Module: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/fac-notes.html
      October 01, 2020 - Empower Frontline Staff Say: Empower Frontline Staff Facility leads should encourage all staff

2429. Clostridium difficile Infections | Agency for Healthcare Research and Quality
      www.ahrq.gov/topics/clostridium-difficile-infections.html
      Topic: Clostridium difficile Infections AHRQ has research, tools, and resources for preventing or reducing Clostridium difficile , a healthcare-associated infection. Healthcare-associated infections are among the leading threats to patient safety, affecting one out of every 31 hospital patients at any one time. …

2430. Artifacts of Culture Change Self-Assessment Tool | Agency for Healthcare Research and Quality
      www.ahrq.gov/nursing-home/resources/artifacts-of-culture-change.html
      June 01, 2021 - Artifacts of Culture Change Self-Assessment Tool Resource:  Artifacts of Culture Change Self-Assessment Tool (PDF, 126 KB) This self-assessment tool can be used by nursing homes on a culture change journey to become aware of concrete changes that leading homes have made to their policies, practices, and envi…

2431. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38407/psn-pdf
      February 11, 2009 - The science and economics of improving clinical communication. February 11, 2009 O'Byrne WT, Weavind L, Selby J. The science and economics of improving clinical communication. Anesthesiol Clin. 2008;26(4):729-44, vii. doi:10.1016/j.anclin.2008.07.010. https://psnet.ahrq.gov/issue/science-and-economics-improving-cl…

2432. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36096/psn-pdf
      September 28, 2010 - How a series of errors led to recurrent hypoglycemia. September 28, 2010 Singh R. How a series of errors led to recurrent hypoglycemia. J Fam Pract. 2006;55(6):489-97. https://psnet.ahrq.gov/issue/how-series-errors-led-recurrent-hypoglycemia This case study illustrates how therapeutic duplication can lead to harm a…

2433. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37421/psn-pdf
      February 15, 2011 - Prescription for error: process defects in a community retail pharmacy. February 15, 2011 Witte D, Dundes L. Prescription for Error. J Patient Saf. 2008;3(4). doi:10.1097/pts.0b013e31815a613e. https://psnet.ahrq.gov/issue/prescription-error-process-defects-community-retail-pharmacy This study used direct observati…

2434. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42735/psn-pdf
      November 13, 2013 - ECRI announces top 10 healthcare technology hazards. November 13, 2013 Clark C. HealthLeaders Media. November 5, 2013. https://psnet.ahrq.gov/issue/ecri-announces-top-10-healthcare-technology-hazards This article summarizes an annual report that spotlights health technologies that may lead to patient harm. https:/…

2435. Fostering Emotional Wellbeing Among Team Members | Agency for Healthcare Research and Quality
      www.ahrq.gov/nursing-home/resources/fostering-emotional-wellbeing.html
      June 01, 2022 - Fostering Emotional Wellbeing Among Team Members Resource: Fostering Emotional Wellbeing Among Team Members ​This "QuickCast" explains why a comprehensive systems approach to supporting the emotional wellbeing of all members of an organization is so important. Source: Leading Age Topic(s): Staff and R…

2436. Vaccine Confidence Insights: Interview with Dr. Simon Mittal | Agency for Healthcare Research and Quality
      www.ahrq.gov/nursing-home/resources/vaccine-confidence-insights.html
      August 01, 2022 - Vaccine Confidence Insights: Interview with Dr. Simon Mittal Resource: Vaccine Confidence Insights: Interview with Dr. Simon Mittal In this interview, Dr. Simon Mittal, a leader with the Minnesota Association of Geriatrics Inspired Clinicians, discusses his experiences with vaccine hesitancy among healthcar…

2437. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining.html
      November 01, 2017 - It also asks which staff members are invited, who leads the meeting, and how often it occurs.

2438. 009-Ss-Evidence-Decolonization-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/009-ss-evidence-decolonization-fg.docx
      April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI The Evidence for MRSA Decolonization Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries Slide Title and Commentary Slide Number and Slide The Evidence for MRSA Decolonization SAY: Welcome to this presentation on the evi…

2439. Providing Evidence and Developing a Toolkit to Accelerate the Adoption of Patient Photographs in Electronic Health Records | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/providing-evidence-and-developing-toolkit-accelerate-adoption-patient
      July 31, 2023 - Providing Evidence and Developing a Toolkit to Accelerate the Adoption of Patient Photographs in Electronic Health Records Project Final Report ( PDF , 1.49 MB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for…

2440. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-471
      December 31, 2024 - January 22, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, report…