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effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/white-paper-lumbar-spondylolisthesis.pdf
March 01, 2021 - White Paper: Standardized Library of Lumbar Spondylolisthesis Outcome Measures
Research White Paper
Standardized Library of Lumbar Spondylolisthesis
Outcome Measures
Research White Paper
Standardized Library of Lumbar Spondylolisthesis
Outcome Measures
Prepared for: …
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs024556-vest-final-report-2019.pdf
January 01, 2019 - Use of Push and Pull Health Information Exchange Technologies by Ambulatory Care Practices and the Impact on Potentially Avoidable Health Care Utilization - Final Report
Final Report
Title: Use of push and pull health inf…
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psnet.ahrq.gov/web-mm/unfamiliar-catheter
November 01, 2006 - and procedures and use best practices when managing a patient with a CVC.( 8 ) This may not always occur
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digital.ahrq.gov/sites/default/files/docs/publication/KSchultzetal2006HFES_JobTaskAnalysis.pdf
January 01, 2005 - Development of a Job Task Analysis Tool for Assessing the Work of Physicians in the Intensive Care Unit
DEVELOPMENT OF A JOB TASK ANALYSIS TOOL FOR ASSESSING THE WORK
OF PHYSICIANS IN THE INTENSIVE CARE UNIT
Kara Schultz*~, Jason Slagle±, Roger Brown†, Steve Douglas*, Brian Frederick*, Manisha
Lakhani*, Jesse …
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psnet.ahrq.gov/web-mm/central-line-clot
August 04, 2021 - The majority of thrombotic episodes in the pediatric population occur as a complication of central venous
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psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
January 01, 2021 - Spotlight
Spotlight
Two Cases of Retained Vaginal Packing:
When Writing an Order is Not Enough
Source and Credits
• This presentation is based on the April 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Verna Gibbs, MD
o AHRQ W…
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psnet.ahrq.gov/node/49829/psn-pdf
May 01, 2018 - As this case
illustrates, no true learning may occur and the problem investigated may be just as likely
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psnet.ahrq.gov/node/49588/psn-pdf
August 01, 2009 - If unpredictable events occur, staff nurses must feel empowered to voice concerns and
collaborate with
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psnet.ahrq.gov/web-mm/customer-always-right
January 22, 2014 - SPOTLIGHT CASE
The "Customer" Is Always Right
Citation Text:
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar BibTeX EndNote…
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psnet.ahrq.gov/web-mm/moving-pains
August 17, 2017 - Hospitals often retrospectively identify these risk factors after sentinel events occur (eg, patients
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psnet.ahrq.gov/node/39743/psn-pdf
October 13, 2010 - Anatomy and pathophysiology of errors occurring in
clinical radiology practice.
October 13, 2010
Brook OR, O'Connell AM, Thornton E, et al. Quality initiatives: anatomy and pathophysiology of errors
occurring in clinical radiology practice. Radiographics. 2010;30(5):1401-10. doi:10.1148/rg.305105013.
https://psnet…
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digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/WhatIsWorkflow.ppt
January 01, 2009 - It can occur at different and/or multiple levels (e.g., one person, between people, across organizations … )
It can occur sequentially and/or simultaneously
Work flows in different ways
Inter-organizational
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psnet.ahrq.gov/node/37155/psn-pdf
October 06, 2011 - Classification of adverse events occurring in a surgical
intensive care unit.
October 6, 2011
Frankel H, Sperry J, Kaplan L, et al. Classification of adverse events occurring in a surgical intensive care
unit. Am J Surg. 2007;194(3):328-32.
https://psnet.ahrq.gov/issue/classification-adverse-events-occurring-surgi…
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psnet.ahrq.gov/node/867137/psn-pdf
November 13, 2024 - Enteral nutrition: an underappreciated source of patient
safety events.
November 13, 2024
Citty SW, Chew M, Hiller LD, et al. Enteral nutrition: an underappreciated source of patient safety events.
Nutr Clin Prac. 2024;39(4):784-799. doi:10.1002/ncp.11153.
https://psnet.ahrq.gov/issue/enteral-nutrition-underapprec…
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hcup-us.ahrq.gov/reports/factsandfigures/2009/pdfs/FF_2009_exhibit5_2.pdf
January 01, 2009 - 5.2A
HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2009 65
EXHIBIT 5.2 Common Conditions During Hospital Stays for Females
5.3
6.4
1.1
1.21.4
1.91.5
1.91.9
2.13.1
2.7
2.2
2.1
4.6
0
5
10
15
20
25
Male Stays
16.4 Million Stays
(42% of All Stays)
Female Stays
22.…
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psnet.ahrq.gov/node/38360/psn-pdf
March 18, 2010 - Medication errors occurring with the use of bar-code
administration technology.
March 18, 2010
PA-PSRS Patient Saf Advis. December 2008;5:122-126.
https://psnet.ahrq.gov/issue/medication-errors-occurring-use-bar-code-administration-technology
This article describes errors associated with bar coded medication admin…
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psnet.ahrq.gov/node/73067/psn-pdf
March 24, 2021 - Changes in error patterns in unanticipated trauma deaths
during 20 years: in pursuit of zero preventable deaths.
March 24, 2021
LaGrone LN, McIntyre LK, Riggle A, et al. Changes in error patterns in unanticipated trauma deaths during
20 years: In pursuit of zero preventable deaths. J Trauma Acute Care Surg. 2020;89…
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www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/child-maltreatment-interventions-draft-rec-bulletin.pdf
September 25, 2023 - U.S. Preventive Services Task Force Issues Draft Recommendation Statement on Primary Care Interventions to Prevent Child Maltreatment
www.uspreventiveservicestaskforce.org 1
U.S. Preventive Services Task Force Issues Draft Recommendation
Statement on Primary Care Interventions to Prevent
Child Maltreatmen…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/TND-0775-150722.pdf
May 12, 2015 - TND-0775-150722
Treatments for Adults with Schizophrenia
Nomination Summary Document
Results of Topic Selection Process & Next Steps
§ This topic will go forw…
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hcup-us.ahrq.gov/reports/factsandfigures/2009/exhibit5_2.jsp
January 01, 2009 - Facts and Figures Exhibit 5.2
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