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2441. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35727/psn-pdf
      February 22, 2006 - Risk of medication errors at hospital discharge and barriers to problem resolution. February 22, 2006 Enguidanos SM; Brumley RD. https://psnet.ahrq.gov/issue/risk-medication-errors-hospital-discharge-and-barriers-problem-resolution The authors reviewed discharge medication records for elderly patients to assess do…

2442. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39153/psn-pdf
      December 02, 2009 - Checking the right boxes, but failing the patient. December 2, 2009 Rifkin D. New York Times. November 16, 2009;Science Desk:5. https://psnet.ahrq.gov/issue/checking-right-boxes-failing-patient Reporting on cases of miscommunication and missed diagnosis, this news column illustrates how strictly following quality …

2443. Module 2—The Infection Preventionist—The Nursing Home Infection Preventionist Training Course | Agency for Healthcare Research and Quality
      www.ahrq.gov/nursing-home/resources/module-2-infection-preventionist.html
      May 01, 2022 - Module 2—The Infection Preventionist—The Nursing Home Infection Preventionist Training Course Resource: Module 2—The Infection Preventionist—The Nursing Home Infection Preventionist Training Course This module describes the role of an infection preventionist, who serves as the lead of a infection prevention…

2444. State Variations in Inpatient Stays for Substance Use Disorders | Agency for Healthcare Research and Quality
      www.ahrq.gov/data/infographics/sud-inpatient-stays.html
      May 01, 2022 - State Variations in Inpatient Stays for Substance Use Disorders   State Variations in Inpatient Stays for Substance Use Disorders  (PDF, 586 KB) Source:  AHRQ, Healthcare Cost and Utilization Project Statistical Brief #289:  Geographic Variation in Inpatient Stays for Five Leading Substance Use Disorders,…

2445. Methicillin-Resistant Staphylococcus aureus (MRSA) | Agency for Healthcare Research and Quality
      www.ahrq.gov/topics/methicillin-resistant-staphylococcus-aureus-mrsa.html
      Topic: Methicillin-Resistant Staphylococcus aureus (MRSA) Methicillin resistant Staphylococcus aureus (MRSA), is a healthcare-associated infection (HAI). HAIs are among the leading threats to patient safety, affecting one out of every 31 hospital patients at any one time. AHRQ has research, tools, programs and reso…

2446. eHealth BP Control Program - 2010 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/ehealth-bp-control-program/annual-summary/2010
      January 01, 2010 - eHealth BP Control Program - 2010 Project Name eHealth Blood Pressure Control Program Principal Investigator Eaton, Charles B. Organization Memorial Hospital of Rhode Island Funding Mechanism RFA: HS08-269: Exploratory and Developmental Grant to Improve Health Care …

2447. A multi-hospital before–after observational study using a point-prevalence approach with an infusion safety intervention bundle to reduce intravenous medication administration errors. | PSNet
      psnet.ahrq.gov/issue/multi-hospital-after-observational-study-using-point-prevalence-approach-infusion-safety
      January 23, 2017 - Study A multi-hospital before–after observational study using a point-prevalence approach with an infusion safety intervention bundle to reduce intravenous medication administration errors. Citation Text: Schnock KO, Dykes PC, Albert J, et al. A Multi-hospital Before-After Observational …

2448. The Give Teens Vaccines Study - 2010 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/give-teens-vaccines-study/activity/give-teens-vaccines-study/annual-summary/2010
      January 01, 2010 - The Give Teens Vaccines Study - 2010 Project Name The Give Teens Vaccines Study Principal Investigator Fiks, Alexander Organization The Children's Hospital of Philadelphia Pediatric Research Consortium Contract Number 290-07-10013-4 Project Period September …

2449. An estimate of missed pediatric sepsis in the emergency department. | PSNet
      psnet.ahrq.gov/issue/estimate-missed-pediatric-sepsis-emergency-department
      December 08, 2021 - Study An estimate of missed pediatric sepsis in the emergency department. Citation Text: Cifra CL, Westlund E, Ten Eyck P, et al. An estimate of missed pediatric sepsis in the emergency department. Diagnosis (Berl). 2020;8(2):193-198. doi:10.1515/dx-2020-0023. Copy Citation Format:…

2450. Teamwork- Part 1: Divided We Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem Problem. | PSNet
      psnet.ahrq.gov/issue/teamwork-part-1-divided-we-fall-part-2-cursed-knowledge-building-culture-psychological-safety
      August 02, 2015 - Commentary Emerging Classic Teamwork- Part 1: Divided We Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem Problem. Citation Text: Rosenbaum L. Divided We Fall. N Engl J Med. 2019;380(7):684-688. doi:10…

2451. Systems analysis of adverse drug events. | PSNet
      psnet.ahrq.gov/issue/systems-analysis-adverse-drug-events
      February 10, 2011 - Study Classic Systems analysis of adverse drug events. Citation Text: Leape L, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274(1):35-43. Copy Citation Format: Google Scholar PubMed B…

2452. Kick-off Visit Check List (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/skills-qi-kickoff.pdf
      June 02, 2025 - Kick-off Visit Check List KICK-OFF VISIT CHECK LIST PRACTICE ENHANCEMENT ASSISTANT ACADEMIC DETAILER Four weeks before visit Contact AD and introduce yourself Determine ABCS assignment Print Baseline Reports & send to AD Four weeks before visit   Negotiate with Nicole Travis date/time   Record ABCS …

2453. Near-miss and maternal sepsis mortality: a qualitative study of survivors and support persons. | PSNet
      psnet.ahrq.gov/issue/near-miss-and-maternal-sepsis-mortality-qualitative-study-survivors-and-support-persons
      October 11, 2023 - Study Near-miss and maternal sepsis mortality: a qualitative study of survivors and support persons. Citation Text: Bauer ME, Perez SL, Main EK, et al. Near-miss and maternal sepsis mortality: a qualitative study of survivors and support persons. Eur J Obstet Gynecol Reprod Biol. 2024;29…

2454. A contemporary analysis of closed claims related to wrong site surgery. | PSNet
      psnet.ahrq.gov/issue/contemporary-analysis-closed-claims-related-wrong-site-surgery
      March 03, 2021 - Study A contemporary analysis of closed claims related to wrong site surgery. Citation Text: Tan J, Ross JM, Wright D, et al. A contemporary analysis of closed claims related to wrong site surgery. Jt Comm J Qual Patient Saf. 2023;49(5):265-273. doi:10.1016/j.jcjq.2023.02.002. Copy Cit…

2455. Opioid prescribing for opioid-naive patients in emergency departments and other settings: characteristics of prescriptions and association with long-term use. | PSNet
      psnet.ahrq.gov/issue/opioid-prescribing-opioid-naive-patients-emergency-departments-and-other-settings
      August 29, 2018 - Study Opioid prescribing for opioid-naive patients in emergency departments and other settings: characteristics of prescriptions and association with long-term use. Citation Text: Jeffery MM, Hooten M, Hess EP, et al. Opioid Prescribing for Opioid-Naive Patients in Emergency Departments …

2456. Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. | PSNet
      psnet.ahrq.gov/issue/changes-prescription-and-over-counter-medication-and-dietary-supplement-use-among-older
      May 06, 2020 - Study Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. Citation Text: Qato DM, Wilder J, Schumm P, et al. Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Olde…

2457. Safety and efficiency of a new generic package labelling: a before and after study in a simulated setting. | PSNet
      psnet.ahrq.gov/issue/safety-and-efficiency-new-generic-package-labelling-and-after-study-simulated-setting
      January 08, 2025 - Study Safety and efficiency of a new generic package labelling: a before and after study in a simulated setting. Citation Text: Garcia BH, Elenjord R, Bjornstad C, et al. Safety and efficiency of a new generic package labelling: a before and after study in a simulated setting. BMJ Qual S…

2458. Patient record review of the incidence, consequences, and causes of diagnostic adverse events. | PSNet
      psnet.ahrq.gov/issue/patient-record-review-incidence-consequences-and-causes-diagnostic-adverse-events
      July 02, 2014 - Study Patient record review of the incidence, consequences, and causes of diagnostic adverse events. Citation Text: Zwaan L, de Bruijne M, Wagner C, et al. Patient record review of the incidence, consequences, and causes of diagnostic adverse events. Arch Intern Med. 2010;170(12):1015-21…

2459. Error reduction in trauma care: lessons from an anonymized, national, multicenter mortality reporting system. | PSNet
      psnet.ahrq.gov/issue/error-reduction-trauma-care-lessons-anonymized-national-multicenter-mortality-reporting
      March 24, 2021 - Study Error reduction in trauma care: lessons from an anonymized, national, multicenter mortality reporting system. Citation Text: Hamad DM, Mandell SP, Stewart RM, et al. Error reduction in trauma care: Lessons from an anonymized, national, multicenter mortality reporting system. J Trau…

2460. Centers for Education and Research on Therapeutics (CERTs) Program (U18) | Digital Healthcare Research
      digital.ahrq.gov/funding-mechanism/centers-education-and-research-therapeutics-certs-program-u18
      January 01, 2023 - Centers for Education and Research on Therapeutics (CERTs) Program (U18) The effects of electronic prescribing by community-based providers on ambulatory medication safety. Citation Abramson EL, Pfoh ER, Barrón Y, et al. The effects of electronic prescribing by community-based…