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psnet.ahrq.gov/web-mm/death-pca
January 06, 2017 - While deaths from PCAs are rare, they can occur and this heightens the importance of developing safe
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - Dealing with issues of compensation
While an error in communication did occur in this case, it likely
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psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
April 01, 2015 - SPOTLIGHT CASE
Pseudo-obstruction But a Real Perforation
Citation Text:
Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
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psnet.ahrq.gov/node/49729/psn-pdf
April 01, 2015 - Misdiagnosis can occur when patients present with mild illness, when symptoms are suggestive of
another
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psnet.ahrq.gov/node/49744/psn-pdf
October 01, 2015 - However, cases like the one presented above, which we had hoped would become a distant memory, still
occur
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psnet.ahrq.gov/node/73300/psn-pdf
July 01, 2022 - testing after discharge.7,8
Insufficient patient understanding of care and care needs: Many readmissions occur
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psnet.ahrq.gov/node/851870/psn-pdf
July 31, 2023 - In Conversation with... Regina Hoffman about Building
Capacity for Patient Safety
July 31, 2023
In Conversation with.. Regina Hoffman about Building Capacity for Patient Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety
Editor’s no…
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psnet.ahrq.gov/node/73200/psn-pdf
April 28, 2021 - preventable condition that is most commonly seen in patients with type 1 diabetes,
but it can also occur
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psnet.ahrq.gov/node/60865/psn-pdf
August 31, 2020 - In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-
BC-FACHE
August 31, 2020
In Conversation With.. Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
Editor’s Note: Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is …
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psnet.ahrq.gov/node/49810/psn-pdf
November 01, 2017 - medication should be done to treat symptoms, not as a preventive
standard procedure in case symptoms might occur
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hcup-us.ahrq.gov/reports/methods/2011_06.pdf
January 01, 2011 - The
readmission could occur at any hospital and was not limited to the hospital of the index
admission … influence patient safety indicators are too new in development or too remote from
where safety problems occur … Also, medical errors and their prevention occur at the
provider, not the state, level.
-
hcup-us.ahrq.gov/reports/methods/2010_06.pdf
January 01, 2010 - The
readmission could occur at any hospital and was not limited to the hospital of the index
admission … influence patient safety indicators are too new in development or too remote from
where safety problems occur … Also, medical errors and their prevention occur at the
provider, not the state, level.
-
effectivehealthcare.ahrq.gov/sites/default/files/nursing-home-safety_disposition-comments.pdf
May 27, 2016 - Does self-neglect occur among older adults with
dementia when unsupervised in Assisted Living? … safety outcomes, given that some degree
of decline and associated clinical events
will certainly occur … Approximately between 1% and 11% of all completed suicides
in older adults occur in nursing homes (Reiss … “push-fall” episodes) because a large number of falls
and injuries occur during these episodes. … We have revised the text for GQ1b to
note that transitions may occur to and
from multiple settings
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-implementation-handouts.pdf
July 01, 2016 - scheduled on my unit on Monday
and Thursday, the routine visits on Nancy’s [Nurse Manager A’s] unit occur … Program Champion: We often schedule briefs held with dietary, social services, and rehab that
occur
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cdsic.ahrq.gov/sites/default/files/2025-09/For%20508%20Approval_MO%20Level%203%20Respondent%20Burden%20Report%208.21.25.pdf
January 01, 2025 - Increase readability and accessibility
- Inform individuals ahead of time when
data collection may occur … accessibility
of data collection tools
- Inform individuals ahead of time
when data collection may occur … This can occur several ways, such as data collection that is
duplicated due to lack of coordination … Discussion
Respondent burden is a multifaceted issue that can occur throughout the PC CDS lifecycle
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digital.ahrq.gov/sites/default/files/For%20508%20Approval_MO%20Level%203%20Respondent%20Burden%20Report%208.21.25.pdf
September 01, 2025 - Increase readability and accessibility
- Inform individuals ahead of time when
data collection may occur … accessibility
of data collection tools
- Inform individuals ahead of time
when data collection may occur … This can occur several ways, such as data collection that is
duplicated due to lack of coordination … Discussion
Respondent burden is a multifaceted issue that can occur throughout the PC CDS lifecycle
-
effectivehealthcare.ahrq.gov/sites/default/files/diabetes-horizon-scan-high-impact-1406.pdf
September 26, 2014 - T1DM can occur at any age but is most often diagnosed in children, adolescents, or young adults.
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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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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…