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  1. 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.
  2. 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…
  3. 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
  4. 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
  5. 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
  6. 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…
  7. 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.
  8. 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
  9. 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
  10. 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
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. 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…
  17. 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…
  18. 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.…
  19. 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…
  20. 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…