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2961. Communication Assessment Guide: Appendix 2 | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/ap2.html
      August 01, 2022 - from this care to determine exactly what happened so we can hopefully prevent something like this from occurring

2962. Slow Down: Right Drug, Wrong Formulation | PSNet
      psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
      October 13, 2018 - formulations with earlier and 2 to 4 times higher peak levels as well as more peak-to-trough level variation occurring

2963. Comparative Effectiveness Review No. 262_Pharmacotherapy for Adults With Alcohol Use Disorder in Outpatient Settings: Systematic Review (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-262-pharmacotherapy-alcohol-summary.pdf
      November 01, 2023 - with each other) for men or women, older adults, young adults, persons who smoke, or those with co-occurring

2964. OY2 Innovation Center Charter (pdf file)
      cdsic.ahrq.gov/sites/default/files/2024-12/OY2%20Innovation%20Center%20Charter_508.pdf
      January 01, 2024 - the Cores should undertake as well as inform the Innovation Center about related PC CDS activities occurring

2965. Checklist for Working with the NEDS
      hcup-us.ahrq.gov/db/nation/neds/nedschecklist.jsp
      November 01, 2024 - Only conditions, procedures, and diagnostic tests occurring during a specific inpatient hospital encounter

2966. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/IAWG-October2024-mtg.pdf
      January 17, 2025 - CDC has investigated this practice using CMS data and can confirm that this testing is occurring, and

2967. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/hacrate2013_0.pdf
      October 01, 2015 - incidents of harm occurred in 2011, 2012, and 2013 (compared to 2010), with most of the improvement occurring

2968. S103 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/s103.pdf
      October 01, 2007 - ORIGINAL ARTICLE Using Inverse Probability-Weighted Estimators in Comparative Effectiveness Analyses With Observational Databases Lesley H. Curtis, PhD,*† Bradley G. Hammill, MS,* Eric L. Eisenstein, DBA,*† Judith M. Kramer, MD, MS,* and Kevin J. Anstrom, PhD*‡ Abstract: Inverse probability-weighted estimation is a…

2969. S23 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/s23.pdf
      October 01, 2007 - ORIGINAL ARTICLE Improving Depiction of Benefits and Harms Analyses of Studies of Well-Known Therapeutics and Review of High-Impact Medical Journals Artyom Sedrakyan, MD, PhD,*†‡ and Chuck Shih, MHS* Abstract: The issues of weighing benefits and harms and of shared decision-making have become increasingly important…

2970. Improving Accuracy of Electronic Notes Using a Faster, Simpler Approach - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs023631-payne-final-report-2018.pdf
      January 01, 2018 - Improving Accuracy of Electronic Notes Using a Faster, Simpler Approach - Final Report …

2971. Best Practices in the Diagnosis and Treatment of Diverticulitis and Biliary Tract Infections (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/diverticulitis-biliary-infections-facilitator-guide.pdf
      November 01, 2019 - Best Practices in the Diagnosis and Treatment of Diverticulitis and Biliary Tract Infections AHRQ Safety Program for Improving Antibiotic Use 1 AHRQ Pub. No. 17(20)-0028-EF November 2019 Best Practices in the Diagnosis and Treatment of Diverticulitis and Biliary Tract Infections Acute…

2972. Challenges to Real-Time Decision Support in Health Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Fitzgerald_108.pdf
      January 01, 2007 - Challenges to Real-Time Decision Support in Health Care Challenges to Real-Time Decision Support in Health Care Mark Fitzgerald, MB, BS, FACEM; Nathan Farrow, RN, BN (Hons) Adv Nur (Critical Care); Pamela Scicluna, BSc; Angela Murray, RN; Yan Xiao, PhD; Colin F. Mackenzie, MBChB, FRCA, FCCM Abstract This …

2973. Critical Incident | Digital Healthcare Research
      digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/critical-incident
      January 01, 2023 - Critical Incident Description The critical incident method is utilized to identify a process, subprocess, or problem that can be fixed or enhanced. It can also be used to identify a source of a performance deficiency. The technique attempts to find information pertaining to organizational problems, an…

2974. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41568/psn-pdf
      April 05, 2013 - Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. April 5, 2013 Hogan H, Healey F, Neale G, et al. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Qual Saf. 2012;21(9):737-745. doi:10.…

2975. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60348/psn-pdf
      May 20, 2020 - High-priority drug-drug interaction clinical decision support overrides in a newly implemented commercial computerized provider order-entry system: override appropriateness and adverse drug events. May 20, 2020 Edrees H, Amato MG, Wong A, et al. High-priority drug-drug interaction clinical decision support overrid…

2976. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47524/psn-pdf
      June 19, 2019 - Learning from patients' experiences related to diagnostic errors is essential for progress in patient safety. June 19, 2019 Giardina TD, Haskell H, Menon S, et al. Learning From Patients' Experiences Related To Diagnostic Errors Is Essential For Progress In Patient Safety. Health Aff (Millwood). 2018;37(11):1821-18…

2977. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44831/psn-pdf
      January 27, 2016 - IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events. January 27, 2016 Adler L, Moore J, Federico F. Cambridge, MA: Institute for Healthcare Improvement; November 2015. https://psnet.ahrq.gov/issue/ihi-skilled-nursing-facility-trigger-tool-measuring-adverse-events Prior research has shown that sa…

2978. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37940/psn-pdf
      June 16, 2010 - Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not? June 16, 2010 Weissman JS, Schneider EC, Weingart SN, et al. Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do n…

2979. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45231/psn-pdf
      February 14, 2017 - 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. February 14, 2017 Barker AL, Morello RT, Wolfe R, et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. BMJ. 2016;352:h6781. doi:10.1136/bmj.h6781. https://psnet.…

2980. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42103/psn-pdf
      January 07, 2015 - Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE). January 7, 2015 Galanter W, Falck S, Burns M, et al. Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE). J Am Med Inform Assoc. 2013;20(3…