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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017276-burns-final-report-2011.pdf
January 01, 2011 - Breakdown may occur at each
point in a person with poor glycemic control.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/handouts.html
September 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits
Facilitator Training—Handouts: Preventable Hospital and ED Visits Implementation
Implementation of Preventable Hospital and ED Visits Reports
Self-Assessment Scripted Exercise
Menu of Implementation…
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017189-trivedi-final-report-2010.pdf
January 01, 2010 - , unlike the visit schedule for STAR*D, clinic visits for EHR-CDSS implemented
MBC was designed to occur … During study 2, clinic visits for MBC were expected to occur on weeks 0 (baseline), 2, 4/6,
8/10, and … Specifically, the improvements in symptom
severity occur earlier, but are balanced out by the end of
-
digital.ahrq.gov/sites/default/files/docs/publication/r18hs017190-chueh-final-report-2011.pdf
January 01, 2011 - difficult to track properly, and 4) chronic disease management where regular testing
and/or followup must occur … results management module in the EHR; 3) implementing
notifications regarding overdue actions so they occur … Expected clinical events are those events (e.g., colonoscopy completed) that must
occur to prevent an
-
www.ahrq.gov/sites/default/files/2025-07/weinger3-report.pdf
January 01, 2025 - healthcare professionals to competently manage acute, even rare critical events;
yet deficiencies occur … designed to: 1) require significant decision making; 2) be
challenging but manageable by BCAs; 3) occur … aspects of individual clinicians’ training and work processes could improve outcomes when these
events occur
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digital.ahrq.gov/sites/default/files/docs/citation/r18hs026189-ko-final-report-2023.pdf
January 01, 2023 - Scaling and Spreading Electronic Capture of Patient-Reported Outcomes Using a National Surgical Quality Improvement Program - Final Report
1
Title of Project: Scaling and Spreading Electronic Capture of Patient-Reported Outcomes Using a
National Surgical Quality Improvement Program
Principal Investig…
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digital.ahrq.gov/sites/default/files/docs/page/guide-to-evaluating-hie-projects-section-6.pdf
June 16, 2021 - providers may not
use an appropriate
indication for a
test, and the call
to the provider
may occur … allergy known
at time of
scheduling)
• Pre- and post-
review of
schedules
Cancellations
may still occur … A callback
episode is
when there is
some back-and-
forth vetting
and multiple
callbacks occur.
-
www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-brief-ai-wave.pdf
June 01, 2025 - rarely make errors, clinicians may
become less vigilant over time and fail to catch the few that do occur—an … Brief recommends that hospitals communicate when AI is involved in care
delivery, this does not always occur
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Teigland.pdf
March 01, 2004 - the extensive Minimum Data Set (MDS)1, 2 assessment data
designed to investigate outcomes after they occur … Many adverse outcomes are preventable and occur due to health care staff’s
limitations as “data processors … avoided (prevented) adverse outcomes (resident identified as very
high risk and adverse event did not occur
-
hcup-us.ahrq.gov/db/vars/dxn/kidnote.jsp
September 01, 2008 - 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
-
psnet.ahrq.gov/node/37533/psn-pdf
April 22, 2011 - Systematic evaluation of errors occurring during the
preparation of intravenous medication.
April 22, 2011
Parshuram CS, To T, Seto W, et al. Systematic evaluation of errors occurring during the preparation of
intravenous medication. CMAJ. 2008;178(1):42-8. doi:10.1503/cmaj.061743.
https://psnet.ahrq.gov/issue/sys…
-
psnet.ahrq.gov/node/60980/psn-pdf
January 01, 2022 - Analysis of risk factors for patient safety events occurring
in the emergency department.
October 7, 2020
Alsabri M, Boudi Z, Zoubeidi T, et al. Analysis of risk factors for patient safety events occurring in the
emergency department. J Patient Saf. 2022;18(1):e124-e135. doi:10.1097/pts.0000000000000715.
https://p…
-
psnet.ahrq.gov/node/35876/psn-pdf
June 18, 2013 - External Inquiry into the adverse incident that occurred at
Queen's Medical Centre, Nottingham, 4th January 2001.
June 18, 2013
Toft B. London, UK; Crown Copyright: 2001.
https://psnet.ahrq.gov/issue/external-inquiry-adverse-incident-occurred-queens-medical-centre-nottingham-
4th-january-2001
This UK Department o…
-
psnet.ahrq.gov/node/42993/psn-pdf
March 19, 2014 - Baccalaureate nursing students' accounts of medical
mistakes occurring in the clinical setting: implications for
curricula.
March 19, 2014
Noland CM. Baccalaureate nursing students' accounts of medical mistakes occurring in the clinical setting:
implications for curricula. J Nurs Educ. 2014;53(3):S34-7. doi:10.392…
-
psnet.ahrq.gov/node/37156/psn-pdf
October 06, 2011 - Preventable harm occurring to critically ill children.
October 6, 2011
Larsen G, Donaldson AE, Parker HB, et al. Preventable harm occurring to critically ill children. Pediatr Crit
Care Med. 2007;8(4):331-336.
https://psnet.ahrq.gov/issue/preventable-harm-occurring-critically-ill-children
This retrospective cohort…
-
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…
-
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…
-
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.…
-
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…
-
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…