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2601. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected | PSNet
      psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
      September 25, 2024 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected Citation Text: Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…

2602. Overview of Hospital Stays in the United States, 2010 (pdf file)
      hcup-us.ahrq.gov/reports/statbriefs/sb144.pdf
      August 01, 2011 - Overview of Hospital Stays in the United States, 2010 1 December 2012 Overview of Hospital Stays in the United States, 2010 Anne Pfuntner, Lauren M. Wier, M.P.H., and Anne Elixhauser, Ph.D. Introduction Inpatient hospital care is a significant component of the health care system, account…

2603. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50881/psn-pdf
      February 12, 2020 - Adverse events during intrahospital transport of critically ill children: a systematic review. February 12, 2020 Haydar B, Baetzel A, Elliott A, et al. Adverse Events During Intrahospital Transport of Critically Ill Children: A Systematic Review. Anesth Analg. 2020;131(4):1135-1145. doi:10.1213/ane.0000000000004585…

2604. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60849/psn-pdf
      January 01, 2021 - Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients. August 26, 2020 Westbrook JI, Li L, Raban MZ, et al. Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients. BM…

2605. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865869/psn-pdf
      May 15, 2024 - The safety of outpatient health care: review of electronic health records. May 15, 2024 Levine DM, Syrowatka A, Salmasian H, et al. The safety of outpatient health care: review of electronic health records. Ann Intern Med. 2024;177(6):738-748. doi:10.7326/m23-2063. https://psnet.ahrq.gov/issue/safety-outpatient-he…

2606. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47691/psn-pdf
      June 02, 2019 - Transfusion safety: the nature and outcomes of errors in patient registration. June 2, 2019 Cohen R, Ning S, Yan MTS, et al. Transfusion Safety: The Nature and Outcomes of Errors in Patient Registration. Transfus Med Rev. 2019;33(2):78-83. doi:10.1016/j.tmrv.2018.11.004. https://psnet.ahrq.gov/issue/transfusion-sa…

2607. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38414/psn-pdf
      March 31, 2009 - Patient safety incidents associated with airway devices in critical care: a review of reports to the UK National Patient Safety Agency. March 31, 2009 Thomas AN, McGrath BA. Patient safety incidents associated with airway devices in critical care: a review of reports to the UK National Patient Safety Agency. Anaes…

2608. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34893/psn-pdf
      February 26, 2009 - The incidence of adverse drug events in two large academic long-term care facilities. February 26, 2009 Gurwitz JH, Field TS, Judge J, et al. The incidence of adverse drug events in two large academic long-term care facilities. Am J Med. 2005;118(3). doi:10.1016/j.amjmed.2004.09.018. https://psnet.ahrq.gov/issue/i…

2609. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35134/psn-pdf
      June 22, 2009 - Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. June 22, 2009 Hillman K, Chen J, Cretikos M, et al. Introduction of the medical emergency team (MET) system: a cluster- randomised controlled trial. Lancet. 2005;365(9477):2091-7. https://psnet.ahrq.gov/issue/introducti…

2610. T.E.A.M.S. infographic | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/improve/teams-infographic.html
      March 01, 2017 - T.E.A.M.S. infographic AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Culture consists of values, attitudes, and beliefs that can have an impact on resident safety, care outcomes, and staff satisfaction. Culture influences how change can occur. T Team Formation The most effective…

2611. 5 Tk2 P2T7-Checklist For Identifying Nursing Home Specific Antibiogram Modifications Phase 2 (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P2T7-Checklist_for_Identifying_Nursing_Home_Specific_Antibiogram_Modifications_Phase_2.doc
      May 01, 2014 - Comprehensive Antibiogram Toolkit: Phase 2 Checklist for Identifying Nursing Home Specific Antibiogram Modifications Wide variation occurs in the format of the antibiogram data provided by laboratories. The format can range from a report that is ready for use by the nursing home with only minor editing to a series of …

2612. Exhibit 2.14. Major Factors that Facilitated Lean Success at Central | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit2-14.html
      November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 2.14. Major Factors that Facilitated Lean Success at Central Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Hea…

2613. AHRQ Impact Case Studies Criteria | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsroom/case-studies/criteria.html
      December 01, 2019 - AHRQ Impact Case Studies Criteria AHRQ Impact Case Studies provide evidence of how AHRQ-funded projects impact health care outcomes, quality, cost, use, and access. Each Impact Case Study demonstrates how AHRQ-funded resources are actually being used to improve the health care system. Impact Case Studies are …

2614. Origin of Adverse Drug Events in U.S. Hospitals, 2011 - Statistical Brief #158
      hcup-us.ahrq.gov/reports/statbriefs/sb158.jsp
      July 01, 2013 - data can be used to chart the frequency of in-hospital events and to report the frequency of community-occurring … The order of the list is from the most to least frequently occurring cause overall. … Clostridium difficile infection was the most common ADE cause, occurring at a rate of 95 per 10,000 … The next two most frequently occurring ADE causes—antineoplastic drugs and steroids—each occurred at

2615. Alcohol-misuse-drug-therapy-140326 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/alcohol-misuse-drug-therapy_research-protocol.pdf
      January 27, 2012 - to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring … men or women, older adults, young adults, racial or ethnic minorities, smokers, or those with co-occurring … women Older adults (65+) Young adults (18-25) Racial/ethnic minorities Smokers Those with co-occurring … For KQ 5, co-occurring disorders will include other mental health disorders (e.g., depression) and acute … and smoking status of enrolled populations; proportion with alcohol dependence and other AUDs; co-occurring

2616. Parent preferences for medical error disclosure: a qualitative study. | PSNet
      psnet.ahrq.gov/issue/parent-preferences-medical-error-disclosure-qualitative-study
      January 25, 2017 - April 12, 2011 Managing the adverse event occurring during elective, ambulatory pediatric

2617. Emergency department boarding and adverse hospitalization outcomes among patients admitted to a general medical service. | PSNet
      psnet.ahrq.gov/issue/emergency-department-boarding-and-adverse-hospitalization-outcomes-among-patients-admitted
      July 13, 2016 - June 30, 2021 Analysis of risk factors for patient safety events occurring in the emergency

2618. Adverse drug event nonrecognition in emergency departments: an exploratory study on factors related to patients and drugs. | PSNet
      psnet.ahrq.gov/issue/adverse-drug-event-nonrecognition-emergency-departments-exploratory-study-factors-related
      April 12, 2011 - More Related Resources Analysis of risk factors for patient safety events occurring

2619. Risk factors for hospital admissions associated with adverse drug events. | PSNet
      psnet.ahrq.gov/issue/risk-factors-hospital-admissions-associated-adverse-drug-events
      October 18, 2018 - October 30, 2010 Medication errors occurring with the use of bar-code administration

2620. Using a preprinted order sheet to reduce prescription errors in a pediatric emergency department: a randomized, controlled trial. | PSNet
      psnet.ahrq.gov/issue/using-preprinted-order-sheet-reduce-prescription-errors-pediatric-emergency-department
      March 04, 2011 - March 4, 2011 Systematic evaluation of errors occurring during the preparation of intravenous