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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery
Citation Text:
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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effectivehealthcare.ahrq.gov/sites/default/files/rfviia.pptx
May 01, 2010 - The Premier database includes information on 40 million annual hospitalizations occurring in 615 U.S. … The Premier database includes information on 40 million annual hospitalizations occurring in 615 U.S.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/rfviia.pptx
May 01, 2010 - The Premier database includes information on 40 million annual hospitalizations occurring in 615 U.S. … The Premier database includes information on 40 million annual hospitalizations occurring in 615 U.S.
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-145-materials-v-a.pdf
June 25, 2014 - Co-occurring mental disorders—
of people with ADHD, what percent
age has 1 or more of the following … co-occurring conditions: sleep dis
orders, learning disabilities, de
pression, anxiety, conduct disorder … were missed and to
strongly consider substance use, de
pression, and anxiety as alternative or
co-occurring … appro
priate diagnostic criteria and proce
dures required to establish a diagno
sis, identify co-occurring … significant costs attributable to greater health-care needs, more frequent unintentional injury, co-occurring
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psnet.ahrq.gov/node/33708/psn-pdf
March 01, 2011 - So there is a handoff occurring at discharge, and
I often think just like you would communicate and
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psnet.ahrq.gov/node/33692/psn-pdf
February 01, 2010 - Handoffs are occurring at multiple levels in the system at the same
time.
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effectivehealthcare.ahrq.gov/sites/default/files/peptic-ulcer-horizon-scan-high-impact-1312.pdf
December 01, 2013 - from PN support.65
The prescribing information states that the most commonly reported adverse events occurring
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case6.html
November 01, 2014 - and process improvement staff noted that they have seen Lean and other process improvement activities occurring … Since Horizon was still quite new during the last set of interviews and adjustments were still occurring
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integrationacademy.ahrq.gov/products/topic-briefs/community-engagement-for-whole-person-care
February 01, 2025 - report having 2 or more chronic conditions, and an estimated 1.2 percent of adults report having a co-occurring … Health System (WHS) Bokhour et al., 2022 25 (Retrospective observational cohort study) Veterans with co-occurring … the regional demographics) and similar to patients served by the other COEs (PDF - 588 KB), have co-occurring
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017196-jack-final-report-2011.pdf
January 01, 2011 - events (ADEs), we used the method developed and refined by
Forster which was adapted to include events occurring … would find out when it started happening, how
severe the patient thought it was, how often it was occurring … Any time a patient reported a side effect, the pharmacist would find out how often it was
occurring
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psnet.ahrq.gov/issue/errors-diagnosis-spinal-epidural-abscesses-era-electronic-health-records
April 24, 2018 - Study
Errors in diagnosis of spinal epidural abscesses in the era of electronic health records.
Citation Text:
Bhise V, Meyer AND, Singh H, et al. Errors in Diagnosis of Spinal Epidural Abscesses in the Era of Electronic Health Records. Am J Med. 2017;130(8). doi:10.1016/j.amjmed.2017.03…
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psnet.ahrq.gov/issue/safety-hospital-stroke-care
December 02, 2020 - Study
The safety of hospital stroke care.
Citation Text:
Holloway RG, Tuttle D, Baird T, et al. The safety of hospital stroke care. Neurology. 2007;68(8):550-555.
Copy Citation
Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/intro.html
November 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention
Introduction
On-Time Falls Prevention was developed to provide the multidisciplinary nursing home team with electronic medical record (EMR)-based tools to effectively monitor resident fall risk and implement proactive strategies to prevent fal…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/injectionsafety.pdf
January 03, 2014 - Injection Safety/Safe Medication Handling
Injection Safety/Safe Medication Handling
The Centers for Disease Control and Prevention has identified 33 hepatitis outbreaks between 1998 and 2008
resulting from deficient health care practices. These outbreaks occurred in outpatient settings such as doctor’s
offices…
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cds.ahrq.gov/sites/default/files/cds/artifact/476/CDS%20Connect%20Pilot%20Site%20Training%20Plan_Final_0.docx
July 23, 2024 - CDS Repository Working Group Charter
CDS Connect Pilot Site Training Plan
PURPOSE: Develop a training plan to get pilot site providers up to speed on the overall project, the pilot objectives and the CDS Connect Pain Management CDS.
TARGET AUDIENCE: Prescribing clinicians at each of the pilot site locations. Qu…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/one-pager-side-effects.pdf
June 01, 2021 - Antibiotic Side Effects
Risk of antibiotic side effects and adverse reactions
• Antibiotic use is the most important risk factor for developing multidrug-resistant infections, which
contribute to over 35,000 deaths in the United States each year
• Antibiotic-associated adverse events are one of the most common rea…
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www.ahrq.gov/patient-safety/reports/engage/interventions/warmhandoff.html
June 01, 2023 - Warm Handoff: Intervention
Patient and Family Engagement in Primary Care
A warm handoff is a transfer of care between two members of the health care team, where the handoff occurs in front of the patient and family. This transparent handoff of care allows patients and families to hear what is said and engages…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0242-technicalspecs.pdf
June 02, 2025 - Follow-up Visits for Children Who Are Obese or Overweight with a Weight-Related Comorbidity: Technical Specifications
The percentage of children, ages 2 through 17 years, with either a BMI >95th percentile or a BMI ≥85th
percentile with weight-related comorbidities, and an outpatient visit, who had at least one sub…
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www.ahrq.gov/nursing-home/materials/prevention/observational-audits.html
July 01, 2021 - Auditing Strategies to Improve Infection Prevention Processes in Nursing Homes
Nursing homes can conduct observational audits to support increased compliance with infection prevention practices, including hand hygiene and use of personal protective equipment.
Observational Audits
Observational audits occur …
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/026-assessing-evc-essential-one-pager.docx
October 01, 2024 - When starting or improving an environmental cleaning (EVC) monitoring program, there are five essential steps to address, which are outlined below. This document focuses on the implementation of fluorescent gel (FG) monitoring, which is generally easier to use and implement, especially when starting a new monitoring pr…