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4541. Improving Patient Safety Through Provider Communication Strategy Enhancements (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Dingley_14.pdf
      February 06, 2008 - Initial pilot testing of huddles occurred within two departments: radiology and laboratory services. … They typically occurred at the beginning of the day or shift, lasted approximately 9 to 20 minutes, … timely, appropriate communication between nursing staff and providers as changes in patient conditions occurred

4542. Overview of Major Ambulatory Surgeries Performed in Hospital-Owned Facilities, 2019 (pdf file)
      hcup-us.ahrq.gov/reports/statbriefs/sb287-Ambulatory-Surgery-Overview-2019.pdf
      January 01, 2019 - Ambulatory Surgery Sample (NASS), 2019 ■ In 2019, 11.9 million encounters for major ambulatory surgeries occurred … ambulatory surgery encounters took place in facilities owned by urban hospitals, and more than 70 percent occurred … performed, including multiple surgeries within or across CCS-Services and Procedures categories that occurred

4543. Acute Renal Failure Hospitalizations, 2005-2014 #231
      hcup-us.ahrq.gov/reports/statbriefs/sb231-Acute-Renal-Failure-Hospitalizations.jsp
      November 01, 2017 - The same pattern occurred for inpatient stays with an all-listed diagnosis of acute renal failure. … Table 3 presents all-listed procedures that occurred most frequently during hospital inpatient stays … single hospitalization could contribute to more than one row in the table if more than one procedure occurred

4544. Recommendation: Latent Tuberculosis Infection in Adults: Screening | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/recommendation/latent-tuberculosis-infection-screening
      May 02, 2023 - In 2020, 71.5% of all cases of active tuberculosis in the US occurred among persons born outside the … In 2020, 4.3% of tuberculosis disease cases diagnosed in persons 15 years or older occurred in persons … experiencing homelessness and 2.6% occurred in residents of correctional facilities. 22 It is estimated

4545. S29 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/s29.pdf
      October 01, 2007 - patient, the equivalence of the drugs (based on current evidence), the level at which randomization occurred … (some subjects thought informed consent would be required if randomiza- tion occurred at the practice … level, but not required if randomization occurred at the plan level), the question of whether medications

4546. Overview of Hospital Stays for Children in the United States, 2012 #187
      hcup-us.ahrq.gov/reports/statbriefs/sb187-Hospital-Stays-Children-2012.jsp
      December 01, 2014 - A similar shift occurred among adults aged 18-44 years, although private insurance continued to pay for … Each of the three respiratory conditions occurred at a rate of 165 to 170 stays per 100,000 population … All other OR procedures occurred in fewer than 20,000 hospital stays and at a rate of fewer than 21 stays

4547. Improving Direct Notification of Abnormal Test Results Via Patient Portals - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs023602-singh-final-report-2017.pdf
      January 01, 2017 - they were incorporated into the test result process map to identify at which step each shortcoming occurred … Data Sources/Collection Aim 1 Data collection occurred between April 2015 and September 2016. … improve the usability of the test result interface.(39;40) In general, the focus group review sessions occurred

4548. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
      January 01, 2020 - opioid-induced respiratory depression; of those, 77% resulted in severe brain damage or death – Most injuries occurred

4549. Making Healthcare Safer Practices: 12. Infusion Pumps (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/infusion-pumps-1.pdf
      March 01, 2020 - reported to the FDA were related to deficiencies in device design and engineering, user errors also occurred … al., 201412 Survey investigated the extent to which standardization of infusion devices has occurred … the providers responsible for ordering, preventing the number of reorders that previously had occurred … Carayon et al., 201014 Nurses attended training sessions on smart intravenous (IV) pump use that occurred … The educational intervention occurred from January to April 2007.

4550. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49477/psn-pdf
      April 01, 2005 - Hold the tPA April 1, 2005 Fagan SC. Hold the tPA. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/hold-tpa The Case A 74-year-old woman with a history of atrial fibrillation on warfarin therapy came to the emergency department (ED) 1 hour after the sudden onset of aphasia and right-sided weakness. A non-co…

4551. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/impmaterials.html
      June 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Hospital Transfer Self-Assessment Worksheet Purpose The Hospital Transfer Self-Assessment Worksheet can help nursing home staff identify and review care that they provide that may lead to avoidable transf…

4552. Understand the Science of Safety Module Alternate Text | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/modules/understand/alt-text.html
      July 01, 2018 - Understand the Science of Safety Module Alternate Text Slide Number and Title Slide Content Content for Alternative Text (Illustration) Slide 1 Cover Slide (CUSP Toolkit logo) The "Understand the Science of Safety" module of the CUSP Toolkit. The CUSP toolkit is a modular approach to pat…

4553. Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides4.html
      October 01, 2017 - Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization Slide Presentation Slide 1: How To Implement the Pressure Injury Prevention Program in Your Organization ADD Hospital Name here Module 4 Slide 2: What We Have Done Thus Far Up to this point, you have: Look…

4554. Dec-2016-Cholesterol-Wg-Notes (doc file)
      cds.ahrq.gov/sites/default/files/workgroups/211/dec-2016-cholesterol-wg-notes.docx
      January 01, 2016 - Cholesterol Management Work Group Meeting Summary Date 12/09/16 Time 2:00 – 4:00 PM EST AGENDA · Welcome and Introductions · CDS Connect Project Overview · CDS Cholesterol Management Work Group Overview and Planning · CDS Cholesterol Management Environmental Scan Findings and Artifacts · CDS Cho…

4555. Chapter 1. Environmental Scan | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program1.html
      April 01, 2018 - Environmental Scan of Patient Safety Education and Training Programs Chapter 1. Environmental Scan Previous Page Next Page Table of Contents Environmental Scan of Patient Safety Education and Training Programs Introduction Chapter 1. Environmental Scan Chapter 2. Electronic Searchable Catalog …

4556. Strategy 3: Bedside Shift Report (Tool 3) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_3_Pres_video_508.pdf
      June 02, 2025 - Strategy 3: Bedside Shift Report (Tool 3) Guide to Patient & Family Engagement Insert hospital logo here Nurse Bedside Shift Report Training [Hospital Name | Presenter name and title | Date of presentation] Strategy 3: Nurse Bedside Shift Report (Tool 3) Today’s session • What is patient and famil…

4557. Using Data To Drive Change and Improve Patient Safety Slides
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/data-change-slides.pptx
      April 01, 2022 - Using Data To Drive Change and Improve Patient Safety Slides Using Data To Drive Change and Improve Patient Safety AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI AHRQ Pub. No. 17(22)-0019 April 2022 Objectives Describe why data are critical to driving improvement in your intensive care …

4558. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Patient and Family Engagement
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/engagement.pptx
      May 01, 2017 - AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Patient and Family Engagement AHRQ Safety Program for Perinatal Care Patient and Family Engagement for Perinatal Safety AHRQ Publication No. 17-0003-6-EF May 2017 1 Learning Objectives 2 AHRQ Safety Program for Perinatal Care Patient & Fam…

4559. Selected Best Practices and Suggestions for Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4d_pdi05-nqi01-pneumothorax-bestpractices.pdf
      May 16, 2016 - Selected Best Practices and Suggestions for Improvement Pediatric Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety 1 Tool D.4d Selected Best Practices and Suggestions for Improvement NQI 01/PDI 05: Iatrogenic Pneumothorax Why focus on iatrogenic pneumothorax in neonat…

4560. Final Report: Modeling Risk and Reducing Liability through Better Communication and Teamwork (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/baker-report.pdf
      January 01, 2024 - Final Report: Modeling Risk and Reducing Liability through Better Communication and Teamwork Agency for Healthcare Research and Quality Modeling Risk and Reducing Liability through Better Communication and Teamwork FINAL REPORT April 2012 Presented to: James Battles Agency for Healthcare Research and Quality …