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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Schade_63.pdf
January 01, 2007 - acute care hospitals.20 Hitcho and coworkers reported a rate of 6.1/1,000 patient-days in
medicine and neurology
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Gandhi_22.pdf
February 01, 2007 - (13.8) 56 (33.1) 19 (13.5) 31 (32.9)
Gastroenterology 56 (21.5) 27 (16.0) 36 (25.5) 13 (13.8)
Neurology
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effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pdf/epc-year-in-review-2021.pdf
January 01, 2021 - Neurology. 2021 Jan 19;96(3):e322-32. doi: 10.1212/WNL.0000000000011278.
Epub 2020 Dec 23.
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digital.ahrq.gov/sites/default/files/docs/citation/ereferralimplementationreportfinal.pdf
February 01, 2012 - 35.4 10.1 25.3 0.4
Hematology 34 10.5 50.2 38.9 7.5 31.4 0.5
Liver 53 1.4 31.4 67.1 14.0 53.1 0.1
Neurology … The percentage of referrals that were “Not Initially
Scheduled” ranged between 9 percent for neurology … The total
proportion of electronic referrals “Never Scheduled” ranged from 4 percent for neurology to … MAY09
JU
L0
9
Month
D
ay
s
Cardiology
Chest
Endocrinology
Gastroenterology
Hematology
Liver
Neurology
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effectivehealthcare.ahrq.gov/sites/default/files/cer-245-breast-reconstruction-after-mastectomy-disposition-comments.pdf
October 01, 2021 - Disposition of Comments_Comparative Effectiveness Review No. 245: Breast Reconstruction After Mastectomy
Comparative Effectiveness Review Disposition of Comments Report
Research Title: Breast Reconstruction After Mastectomy: A Systematic Review and Meta-
Analysis
Draft report available for public comme…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/diagnostic-error-executive-summary.pdf
August 01, 2023 - Comparative Effectiveness Review No. 258_Diagnostic Errors in the Emergency Department: A Systematic Review
Comparative Effectiveness Review
Number 258
Diagnostic Errors in the Emergency
Department: A Systematic Review
Evidence Summary
Main Points
• Overall diagnostic accuracy in the emergen…
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psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - Medication Mix-Up: From Bad to Worse
Citation Text:
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNote …
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Tacit Handover, Overt Mishap
Citation Text:
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
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psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
October 26, 2022 - Diagnosing a Missed Diagnosis
Citation Text:
Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-274-tethered-spinal-cord-disposition-comments.pdf
October 25, 2024 - Disposition of Comments_Comparative Effectiveness Review No. 274: Diagnosis and Treatment of Tethered Spinal Cord
Comparative Effectiveness Review Disposition of Comments Report
Title: Diagnosis and Treatment of Tethered Spinal Cord
Draft report available for public comment from February 23, 2024, to…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/slides.html
November 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention
Facilitator Training Slide Presentation
Text version of slide presentation.
Slide 1: Introduction to Falls Reports
AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training
Introduction to Falls Reports
Sl…
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psnet.ahrq.gov/node/49570/psn-pdf
October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure?
October 1, 2008
Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
Case Objectives
Understand the complementary abilities of an electronic health record a…
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psnet.ahrq.gov/node/73456/psn-pdf
June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult
Intubation and Severe Hypoxemia
June 30, 2021
Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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psnet.ahrq.gov/node/49516/psn-pdf
August 01, 2006 - Physical Diagnosis: A Lost Art?
August 1, 2006
Thompson GR, Verghese A. Physical Diagnosis: A Lost Art? PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
Case Objectives
Appreciate the decline in proficiency and reliance on physical examination skills among health care
providers.
…
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psnet.ahrq.gov/node/865376/psn-pdf
March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a
Patient Admitted for Leg Fractures
March 27, 2024
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…
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www.ahrq.gov/hai/cauti-tools/archived-webinars/preventing-cauti-proc-related-catheter-use-slides.html
December 01, 2017 - Preventing CAUTI in Special Populations: Focus on Procedure-Related Catheter Use
Slide presentation
Slide 1
Preventing CAUTI in Special Populations: Focus on Procedure-Related Catheter Use
David A. Pegues, MD
Professor of Medicine, Division of Infectious Diseases
Medical Director, Healthcare Epidemiol…
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - Open wider: Failure to use an interpreter results in
fractured teeth and hypoxia during a simple elective
operation.
December 14, 2022
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia
during a simple elective operation. PSNet [internet]. 2022.
https://psnet.ah…
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www.ahrq.gov/sites/default/files/2024-11/devita-report.pdf
January 01, 2024 - Final Progress Report: METs: Preventing Patient Crisies; Protecting Patients in Crisis
AHRQ Final Report
Title of Project: METs: Preventing Patient Crisies; Protecting Patients in Crisis
AHRQ grant: 1 R13 HS 15757-01
Awarded May, 2005.
Dates of project: May 2005-May 2006.
Date of Conference: June 25 and 26, 2005.
…
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psnet.ahrq.gov/node/49608/psn-pdf
August 01, 2010 - Emergent Triage Miss
August 1, 2010
Travers D. Emergent Triage Miss. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/emergent-triage-miss
The Case
A 42-year-old woman presented to a busy urban emergency department (ED) and approached the triage
nurse. The patient told the triage nurse that she had "3 days o…