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5941. Human Factors Engineering Can Teach You How to Be Surprised Again | PSNet
      psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
      November 01, 2006 - Huge numbers of errors in communication occur for a wide variety of reasons.

5942. Patient Safety: A Perspective from Office Practice | PSNet
      psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
      May 01, 2009 - Download Citation Perspective Most patient interactions with the health care system occur … Many potential and actual safety problems occur there as well.( 1 ) Yet patient safety literature and

5943. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia | PSNet
      psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
      January 29, 2021 - The epidural placement can then occur at a regular pace with optimal positioning and full cooperation

5944. Folic Acid for the Prevention of Neural Tube Defects: Recommendation Statement (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/B8omJCgNDKfJLVXCz6nFw-
      May 01, 2009 - neural tube defect is associated with an in- creased risk for having an affected pregnancy, most cases occur

5945. Fan-Qvpdgnjh8Krdf4Smmv (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/FaN-QvpDgnJh8KrdF4smmv
      May 01, 2013 - DISCUSSION Burden of Disease Each year, approximately 1.5 million osteoporotic fractures occur in the

5946. A National Web Conference on Practical Models to Improve Patient-Clinician Communication Using Health IT (pdf file)
      digital.ahrq.gov/sites/default/files/docs/patient-clinician-communication-slides-121812.pdf
      January 01, 2020 - A National Web Conference on Practical Models to Improve Patient-Clinician Communication Using Health IT A National Web Conference on Practical Models to Improve Patient-Clinician Communication Using Health IT December 18, 2012 2:30pm – 4:00pm ET http://www.ahrq.gov Moderator and Presenters Disclosures …

5947. Layout 1 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/atrial-fibrillation-ablation_executive.pdf
      July 01, 2009 - Cardiac tamponade was reported to occur in 0 percent to 5 percent (median 1 percent) of patients in the

5948. In Conversation With… Vineet Chopra, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
      February 28, 2024 - In Conversation With… Vineet Chopra, MD, MSc October 30, 2019  Citation Text: In Conversation With… Vineet Chopra, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation…

5949. Healthcare Cost and Utilization Project (HCUP) NIS Notes
      hcup-us.ahrq.gov/db/vars/_prn/nisnote.jsp
      September 01, 2008 - coding changes, 3 months before and 3 months after October of each year when ICD-9-CM coding changes occur … coding changes, 3 months before and 3 months after October of each year when ICD-9-CM coding changes occur

5950. Healthcare Cost and Utilization Project (HCUP) NEDS Notes
      hcup-us.ahrq.gov/db/vars/dxn/nedsnote.jsp
      May 01, 2015 - DSM IV codes may occur in the HCUP data. … coding changes, 3 months before and 3 months after October of each year when ICD-9-CM coding changes occur

5951. In Conversation with…William B. Weeks, MD, MBA | PSNet
      psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
      May 01, 2009 - Practice May 1, 2009 Perspective Most patient interactions with the health care system occur … Many potential and actual safety problems occur there as well.( 1 ) Yet patient safety literature and

5952. Development of a Comprehensive Medical Error Ontology (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Mokkarala_103.pdf
      June 16, 2008 - medical errors, and systems failures is a major barrier to understanding where, how, and why problems occur … Two types of mismatches between ontologies have been reported to occur:19, 29, 30 1. … The intersection of these two concepts represents the “Setting” in which an error can occur.

5953. Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Zierler_81.pdf
      September 01, 2008 - Prevention, diagnosis, and treatment of VTE should occur not only during acute hospital care, but also … Randomization will occur at the time of log in, and the provider will be assigned to either the control … Foundation’s annual meeting in Washington, DC, a panel of experts commented on the fact that change will occur

5954. 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…

5955. 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.…

5956. 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…

5957. 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…

5958. U.S. Preventive Services Task Force Issues Draft Recommendation Statement on Primary Care Interventions to Prevent Child Maltreatment (pdf file)
      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…

5959. 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…

5960. Facts and Figures Exhibit 5.2
      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 …