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2981. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44826/psn-pdf
      February 14, 2017 - Validity of the Agency for Healthcare Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: a systematic review and meta-analysis. February 14, 2017 Winters BD, Bharmal A, Wilson RF, et al. Validity of the Agency for Health Care Research and Quality …

2982. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40600/psn-pdf
      September 09, 2011 - To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective. September 9, 2011 Fareed N, Mick SS. To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective. Health Care Manage Rev. 2011;36(4):288-298. doi:10.1097/HMR.0b01…

2983. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46361/psn-pdf
      May 23, 2018 - Inadequate hand-off communication. May 23, 2018 Inadequate hand-off communication. Sentinel event alert. 2017;58(58):1-6. https://psnet.ahrq.gov/issue/inadequate-hand-communication The Joint Commission publishes sentinel event alerts to draw attention to pressing or emerging safety issues and provide guidelines fo…

2984. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42575/psn-pdf
      September 26, 2016 - Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review. September 26, 2016 Raban MZ, Westbrook JI. Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review. BMJ Qual Saf. 2014;23(5):414-21. d…

2985. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867392/psn-pdf
      December 18, 2024 - Large-scale observational study of AI-based patient and surgical material verification system in ophthalmology: real-world evaluation in 37 529 cases. December 18, 2024 Tabuchi H, Ishitobi N, Deguchi H, et al. Large-scale observational study of AI-based patient and surgical material verification system in ophthalm…

2986. Screening for Skin Cancer: Clinical Summary (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/3SeKj9o-FNNwFokLKKzN3f
      Screening for Skin Cancer: Clinical Summary Figure. Screening for Skin Cancer: Clinical Summary Population Asymptomatic adults Recommendation No recommendation. Grade: I (insufficient evidence) Risk Assessment Skin cancer occurs more commonly in men than in women and among persons with a fai…

2987. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42230/psn-pdf
      October 06, 2016 - Using Lean to improve medication administration safety: in search of the "perfect dose." October 6, 2016 Ching JM, Long C, Williams BL, et al. Using lean to improve medication administration safety: in search of the "perfect dose". Jt Comm J Qual Patient Saf. 2013;39(5):195-204. https://psnet.ahrq.gov/issue/using-…

2988. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47876/psn-pdf
      March 27, 2019 - Evaluation of medication errors at the transition of care from an ICU to non-ICU location. March 27, 2019 Tully AP, Hammond DA, Li C, et al. Evaluation of Medication Errors at the Transition of Care From an ICU to Non-ICU Location. Crit Care Med. 2019;47(4):543-549. doi:10.1097/CCM.0000000000003633. https://psnet.…

2989. Clinical Summary: Behavioral Counseling to Prevent Skin Cancer (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/hEz3hmuzj-qYPRWLxucuPc
      Clinical Summary: Behavioral Counseling to Prevent Skin Cancer Clinical Summary: Behavioral Counseling to Prevent Skin Cancer Population Young adults, adolescents, children, and parents of young children with fair skin type Adults older than 24 years with fair skin type Skin self-examination in adults …

2990. USA, CA, Davis | Digital Healthcare Research
      digital.ahrq.gov/location/usa-ca-davis
      January 01, 2023 - USA, CA, Davis School-Based Tele-Physiatry Assistance for Rehabilitative and Therapeutic Services for Children with Special Health Care Needs Living in Rural and Underserved Communities Description This study examined parent and provider experiences and care costs for in-perso…

2991. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35875/psn-pdf
      May 21, 2013 - Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. May 21, 2013 The Joint Commission. https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person- surgery According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approxi…

2992. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39523/psn-pdf
      September 26, 2016 - Association of interruptions with an increased risk and severity of medication administration errors. September 26, 2016 Westbrook JI, Woods A, Rob MI, et al. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170(8):683-690. doi:10.1001/arch…

2993. Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
      January 01, 2023 - • This has a greater chance of occurring if a large proportion of alerts are not relevant or clinically

2994. A Laceration that Needed a Proper Exam, Not an X-Ray | PSNet
      psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
      November 25, 2020 - used by or on patients” and relevant financial relationships as “financial relationships in any amount occurring

2995. A Playbook for Preventing CLABSI and CAUTI in the ICU Setting (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/playbook_revised.pdf
      April 01, 2022 - facilitate analysis of the event to identify root causes and strategies to mitigate the risk of the event’s occurring

2996. Half-Day Training Content | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/intro/teach/half-day.html
      August 01, 2023 - Half-Day Training Content Components you can include in the Introduction for a half-day training include: Quick introductions of trainers and participants : 3 minutes Abbreviated teamwork exercise : 10 minutes Course objectives, overview, resources, and rationale : 2 minutes Patient story video and re…

2997. Getting Ready for Measurement: Overcoming Barriers and Taking Next Steps | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-3.html
      June 01, 2020 - Operational Measurement of Diagnostic Safety: State of the Science Getting Ready for Measurement: Overcoming Barriers and Taking Next Steps Previous Page Next Page Table of Contents Operational Measurement of Diagnostic Safety: State of the Science Introduction Special Considerations for Measure…

2998. A Practice-based Intervention to Improve Care for a Diverse Population of Women with Urinary Incontinence (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/projects/urinary/evidencenow-optima.pdf
      January 01, 2025 - A Practice-based Intervention to Improve Care for a Diverse Population of Women with Urinary Incontinence A Practice-based Intervention to Improve Care for a Diverse Population of Women with Urinary Incontinence Pr This practice-based intervention seeks to improve the quality of care for women with urinary in…

2999. Limitations of AI and the Resulting Risk | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-ai-wave4.html
      July 01, 2025 - Understanding the AI Wave: Foundational Knowledge for Improving Diagnosis and Beyond Limitations of AI and the Resulting Risk Previous Page Next Page Table of Contents Understanding the AI Wave: Foundational Knowledge for Improving Diagnosis and Beyond Introduction Understanding the AI Wave—What…

3000. Enhancing Providers' Ability to Follow Up on Abnormal Test Results | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/enhancing-providers-ability-followup-abnormal-test-results
      January 01, 2023 - Enhancing Providers' Ability to Follow Up on Abnormal Test Results Project Final Report ( PDF , 632.73 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the v…