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  1. 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: …
  2. 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…
  3. 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
  4. 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 …
  5. 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
  6. Spotlight (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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
  8. Psn-Pdf (pdf file)

    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
  9. 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…
  10. psnet.ahrq.gov/web-mm/moving-pains
    August 17, 2017 - Hospitals often retrospectively identify these risk factors after sentinel events occur (eg, patients
  11. Psn-Pdf (pdf file)

    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…
  12. 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
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Ff 2009 Exhibit5 2 (pdf file)

    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.…
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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…
  18. 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…
  19. TND-0775-150722 (pdf file)

    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…
  20. hcup-us.ahrq.gov/reports/factsandfigures/2009/exhibit5_2.jsp
    January 01, 2009 - Facts and Figures Exhibit 5.2 An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs Email Updates …