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psnet.ahrq.gov/web-mm/communication-error-closed-icu
July 01, 2016 - Communication Error in a Closed ICU
Citation Text:
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/missed-appendicitis
March 13, 2013 - SPOTLIGHT CASE
Missed Appendicitis
Citation Text:
Adams JG. Missed Appendicitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/depression-screening-2002
May 07, 2002 - Share to Facebook
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archived
Final Recommendation Statement
Depression: Screening 2002
May 07, 2002
Recommendations made by the USPSTF are independent of the U.S. government. They should…
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - Failure to Rescue the Mother
Citation Text:
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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www.ahrq.gov/sites/default/files/wysiwyg/data/SyH-DR-Data-Request-Guide-Oct24update.pdf
October 01, 2024 - Data Request Guide
Synthetic Healthcare Database for
Research (SyH-DR)
A Synthetic Nationally Representative All-Payer
Claims Database
Data Request Guide
AHRQ Publication No. 24(25)-0019-2-EF
October 2024
SyH-DR Data Request Guide i
Purpose
The Synthetic Healthcare Database for Research (SyH-DR) D…
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www.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
August 01, 2022 - Implementation Guide for the CANDOR Process
Communication and Optimal Resolution Toolkit
Purpose: The Toolkit Implementation Guide is a reference for organizational leaders who are committed to improving their response to unexpected patient harm events. The guide describes the CANDOR process, implementatio…
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psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose
Citation Text:
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4p_combo_pdi02-pressureulcer-bestpractices.pdf
January 01, 2012 - Selected Best Practices and Suggestions for Improvement
Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4p
Selected Best Practices and Suggestions for Improvement
PDI 02: Pressure Ulcer
Why focus on pressure ulcers in children?
• Although children are typi…
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psnet.ahrq.gov/web-mm/good-catch-operating-room
August 27, 2017 - Good Catch in the Operating Room
Citation Text:
Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/860050/psn-pdf
January 04, 2024 - Radiology Missed an Intracranial Bleed in a Lethargic
Infant.
January 4, 2024
Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
The Case
A 2-month-old full-term male infant was b…
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psnet.ahrq.gov/web-mm/too-tight-control
March 20, 2013 - SPOTLIGHT CASE
Too Tight Control
Citation Text:
Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax
Citation Text:
Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/helpful-resources/translating/translating-cahps-surveys.pdf
January 17, 2017 - Translating CAHPS Surveys
Translating CAHPS® Surveys
Contents
Purpose of this Document ............................................................................................................................. 1
Select Translation Team Members ...................................................................…
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psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
October 13, 2018 - Slow Down: Right Drug, Wrong Formulation
Citation Text:
Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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hcup-us.ahrq.gov/reports/race/CostsofDisparitiesIB.pdf
June 24, 2011 - Cost of Disparities Fact Sheet
MAINTAIN AND EXPAND
THE HEALTHCARE COST AND UTILIZATION PROJECT (HCUP)
Contract No. HHSA-290-2006-00009-C
June 24, 2011
Prepared by:
Carrie Hanlon, MA, and Larry Hinkle
Submitted to: Submitted by:
Jenny Schnaier, Proje…
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psnet.ahrq.gov/web-mm/emergency-error
January 18, 2013 - SPOTLIGHT CASE
Emergency Error
Citation Text:
Symons NRA. Emergency Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/thin-air
March 01, 2006 - SPOTLIGHT CASE
Thin Air
Citation Text:
Gaba DM. Thin Air. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/CG/administering_cg_narrative_items.pdf
June 01, 2021 - About the CAHPS Patient Narratives Elicitation Protocol
June 2021
Administering the CAHPS® Clinician &
Group Narrative Item Set
Introduction ......................................................................................................... 1
Placing the Narrative Items in the Survey ......................…
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hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/nm2.jsp
July 01, 2016 - Standardizing the Collection of Race, Ethnicity, and Tribal Affiliation Data.
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psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
January 31, 2024 - The Unhappy Patient Leaves Against Medical Advice.
Citation Text:
Nichols A. The Unhappy Patient Leaves Against Medical Advice.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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