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4561. Facts and Figures Exhibit 3.2
      hcup-us.ahrq.gov/reports/factsandfigures/2008/exhibit3_2.jsp
      January 01, 2008 - Facts and Figures Exhibit 3.2 An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs Email Updates …

4562. Ruptured Heterotopic Pregnancy | PSNet
      psnet.ahrq.gov/web-mm/ruptured-heterotopic-pregnancy
      August 16, 2023 - Ruptured Heterotopic Pregnancy Citation Text: Cedars MI. Ruptured Heterotopic Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

4563. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73146/psn-pdf
      April 28, 2021 - Patient Safety in Home Dialysis April 28, 2021 Morfín JA, Fitall E, Hall KK, et al. Patient Safety in Home Dialysis. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/patient-safety-home-dialysis Dialysis Care and Patient Safety Concerns In patients with chronic kidney disease, kidney function declines ov…

4564. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49467/psn-pdf
      December 01, 2004 - A "Weak" Response December 1, 2004 Reisman AB. A "Weak" Response. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/weak-response The Case A primary care physician on call for his group received a call at 9:00PM from a 68-year-old man. He said, "They started me on a new pill for my blood pressure and now I fe…

4565. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
      February 01, 2014 - PowerPoint Presentation Spotlight Case Multifactorial Medication Mishap 1 This presentation is based on the February 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Annie Yang, PharmD, BCPS NYU Langone Medical Center Editor, AHRQ WebM&M: Robe…

4566. Charcoal Lavage of the Lungs | PSNet
      psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
      January 01, 2016 - Charcoal Lavage of the Lungs Citation Text: Wigton RS. Charcoal Lavage of the Lungs. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …

4567. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49520/psn-pdf
      September 01, 2006 - DNR in the OR and Afterwards September 1, 2006 Lo B. DNR in the OR and Afterwards. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/dnr-or-and-afterwards The Case An 85-year-old woman with dementia took a mechanical fall at her skilled nursing facility (SNF) and suffered a fractured femur. After initial eval…

4568. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49868/psn-pdf
      July 02, 2019 - Delayed Clozapine Prescription in an Elderly Man With Dementia July 2, 2019 Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia The Case An 86-year-old man with neurode…

4569. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843736/psn-pdf
      February 01, 2023 - Saved by ECMO February 1, 2023 Weiss NA. Saved by ECMO . PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/saved-ecmo The Case A 27-year-old pregnant woman was admitted at an estimated gestational age (EGA) of 29 weeks for increased shortness of breath. She was diagnosed with severe pulmonary arterial hyperte…

4570. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.230_slideshow.ppt
      December 01, 2010 - Spotlight Case July 2008 Spotlight Case The Forgotten Turn * * Source and Credits This presentation is based on the December 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Susan Barbour, RN, FNP, University of California San Francisco …

4571. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33844/psn-pdf
      October 01, 2017 - Health Care Worker Presenteeism: A Challenge for Patient Safety October 1, 2017 Szymczak JE. Health Care Worker Presenteeism: A Challenge for Patient Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety Perspective Introduction Health care–as…

4572. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33631/psn-pdf
      April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety April 1, 2006 Alldredge BK, Koda-Kimble MA. Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacis…

4573. 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…

4574. 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

4575. IV. Evaluation Aims, Methods, and Results | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/hotline/eval4.html
      May 01, 2016 - This information was collected as part of the provider supplementation process that occurred 45 days … When patients or caregivers were asked to identify where the mistake or negative effect occurred, 18 … were reported to have occurred in the hospital, seven in the emergency department, and three in a doctor

4576. Improving Patient Safety in Long-Term Care Facilities, Module 1 (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/ltcmodule1.pdf
      June 01, 2012 - the blood pressure cuff and stethoscope, the pulse oximeter, and the thermometer. › See if a change occurred … shift-to-shift comparison. › Make sure the needed equipment is available. › See if a change occurred … Perhaps a small stroke occurred, or the resident has another new medical problem that is contributing

4577. Final Progress Report: EHR-Based Medication Complete Communication Strategy to Promote Safe Opioid Use (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/mccarthy-report.pdf
      January 01, 2024 - Results: Demonstrated safe use occurred more often in the EMC2 group (adjusted odds ratio [aOR], 2.46 … Demonstrated safe use occurred more often in the EMC2-alone group (adjusted odds ratio [aOR], 2.46; … Implementation Analysis: The processes that occurred at the time of the ED visit had a high level of

4578. Final Progress Report: Problem Density, Workload, and Medical Error in Primary Care Practice: a WREN Study (pdf file)
      www.ahrq.gov/sites/default/files/2024-09/temte-report.pdf
      January 01, 2024 - Data collection occurred from August 2007 through March 2008. … Study visits occurred more commonly on Tuesdays (n=136) than expected and less commonly on Fridays … The high score visit occurred for a 74 year-old female continuity patient presenting with acute chest

4579. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 1: Why Patient Narratives Matter (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol1.pdf
      July 01, 2023 - medical mishaps, inducing disparities in error reporting10; or ■ Might erroneously presume errors occurred … research shows that patients and families will report diagnostic experiences when asked if an “error” has occurred … patients to attribute responsibility for a problem, the less likely they are to report that the event occurred

4580. 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