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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Hougland_26.pdf
October 01, 2011 - addition to more refined codes for AEs, specific locations, such as hospital or
nursing home as place of occurrence … Clinical modification codes in discharge abstracts are
poor measures of complication occurrence in medical
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Rivard_97.pdf
April 28, 2008 - We did not include complications of anesthesia or
transfusion reaction because their low occurrence … A study of adverse occurrence and failure to
rescue. Med Care 1992; 30: 615-629.
25.
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - Several factors may have contributed to this occurrence including misinterpretation of her laboratory
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/ace-inhibitor-arb-update_executive.pdf
June 01, 2011 - Comment: Angioedema is a well-known adverse
reaction to ACEIs and ARBs; however, due to its
infrequent occurrence
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psnet.ahrq.gov/web-mm/nothing-called-small-surgery
February 01, 2023 - tourniquets. 32
Ultimately, however, systemic processes need to be implemented to prevent adverse event occurrence
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psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - A study of adverse occurrence and failure to rescue. Med Care. 1992;30:615-629.
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psnet.ahrq.gov/node/72589/psn-pdf
December 23, 2020 - Harvard-affiliated hospitals and practice groups, missed and delayed breast cancer malpractice claims are
a regular occurrence
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psnet.ahrq.gov/node/60856/psn-pdf
August 26, 2020 - Anesthesiologists Physical Status 4 or 5), high-
risk operations (e.g., carotid endarterectomy), or the occurrence
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_data_into_action.pptx
December 01, 2017 - The sooner an infection is recognized, the sooner it can be investigated for its occurrence.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_deep_root_data.pptx
December 01, 2017 - point is to think of your audience and anticipate its questions and informational needs to prevent occurrence
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psnet.ahrq.gov/classics
August 01, 2023 - This analysis examined the occurrence of missed acute cardiac ischemia among over 10...
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psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
August 01, 2009 - guidelines and readily available techniques for healthcare professionals to utilize to prevent its occurrence
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hcup-us.ahrq.gov/reports/methods/2016-03.pdf
January 01, 2016 - Injury-Related Events
First character = "E" and NOT ONE of the following:
E849.0-E849.9 (place of occurrence
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hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/nm2.jsp
July 01, 2016 - Standardizing the Collection of Race, Ethnicity, and Tribal Affiliation Data.
An official website of the Department of Health & Human Services
Search All AHRQ Websites
Careers
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…
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psnet.ahrq.gov/node/865656/psn-pdf
April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous
Combination
April 24, 2024
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous
Combination. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
The Case
A 26-ye…
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psnet.ahrq.gov/node/855057/psn-pdf
October 31, 2023 - Addressing Workplace Violence and Creating a Safer
Workplace
October 31, 2023
Jones CB, Sousane Z, Mossburg S. Addressing Workplace Violence and Creating a Safer Workplace.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
While violence in the w…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
March 12, 2008 - Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes
Evaluation of Medications Removed from Automated
Dispensing Machines Using the Override Function
Leading to Multiple System Changes
Karla Miller, PharmD; Manisha Shah, MBA, RT; Lau…
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psnet.ahrq.gov/node/853773/psn-pdf
September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side.
September 27, 2023
Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
The Case
A first-year orthopedic surgery resident was consulted…
-
psnet.ahrq.gov/node/61078/psn-pdf
October 28, 2020 - Inpatient Stroke Management in an Adolescent with Type
1 Diabetes and Home Insulin Pump
October 28, 2020
Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1
Diabetes and Home Insulin Pump . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/inpatient-stroke-management…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-obhemorrhage.html
July 01, 2023 - Labor and Delivery Unit Safety: Obstetric Hemorrhage
AHRQ Safety Program for Perinatal Care
Purpose of the tool: This tool describes the key perinatal safety elements related to the management obstetric hemorrhage. The key elements are presented within the framework of the Comprehensive Unit-base…