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5941. Chapter 3. Developing Change: Designing the Medication Reconciliation Process | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/match/chapter-3.html
      July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation Chapter 3. Developing Change: Designing the Medication Reconciliation Process Previous Page Next Page Table of Contents Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Recon…

5942. An Overview of the CANDOR Process
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module8/module8-organizational-learning-sustainability.pptx
      August 20, 2015 - An Overview of the CANDOR Process Communication and Optimal Resolution (CANDOR) Toolkit Module 8: Organizational Learning and Sustainability Module 8, the last module in the CANDOR Toolkit, provides an overview of organizational learning and how an organization can develop a sustainability plan to assure the CAND…

5943. Selected Best Practices and Suggestions for Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4d_combo_psi07-crbsi-bestpractices.pdf
      May 20, 2016 - Selected Best Practices and Suggestions for Improvement Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety 1 Tool D.4d Selected Best Practices and Suggestions for Improvement PSI 07: Central Venous Catheter (CVC)-Related Bloodstream Infections (BSIs) Why Focus on Ce…

5944. Summary of Patient Safety Research Opportunities | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/news-events/summit-research-2020/questions.html
      March 01, 2021 - Summary of Patient Safety Research Opportunities AHRQ Summit and Roundtable on Research Priorities for Patient Safety Improvement Research questions, topics, and key themes that were addressed as part of the Patient Safety Roundtable and Patient Safety Summit included the items listed below. It is important t…

5945. Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Deis_82.pdf
      June 03, 2008 - Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement Jamie N. Deis, MD; Keegan M. Smith, MD; Michael D. Warren, MD; Patricia G. Throop, BSN, CPHQ; Gerald B. Hickson, MD; …

5946. Synthesis Report: Methods and Results From the AHRQ Estimating Costs Research Grants | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/reports/cost-guide/synthesis-report.html
      February 01, 2017 - Estimating the Costs of Primary Care Transformation: A Practical Guide and Synthesis Report Synthesis Report: Methods and Results From the AHRQ Estimating Costs Research Grants Previous Page Next Page Table of Contents Estimating the Costs of Primary Care Transformation: A Practical Guide and Synthe…

5947. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49799/psn-pdf
      July 01, 2017 - Delayed Recognition of a Positive Blood Culture July 1, 2017 Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture The Case A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress…

5948. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33723/psn-pdf
      December 01, 2011 - Implementing a Fall Prevention Program December 1, 2011 Healey F. Implementing a Fall Prevention Program. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/implementing-fall-prevention-program Perspective Throughout the developed world, most hospital beds are occupied by older people, many of whom have b…

5949. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33729/psn-pdf
      May 01, 2012 - The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety May 1, 2012 Sharek PJ. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-pa…

5950. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49676/psn-pdf
      February 01, 2013 - Death by PCA February 1, 2013 Hicks RW. Death by PCA. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/death-pca The Case A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …

5951. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49400/psn-pdf
      May 01, 2003 - Central Line Clot May 1, 2003 Randolph AG. Central Line Clot. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/central-line-clot Case Objectives List the complications of central line manipulation Appreciate the limitations of diagnostic studies for PE in children Describe modalities for prevention of cathe…

5952. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33674/psn-pdf
      February 01, 2009 - In Conversation with…Robert M. Wachter, MD October 1, 2008 In Conversation with…Robert M. Wachter, MD. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md Editor's note: At the University of California, San Francisco, Robert M. Wachter, MD, is Professor and Chief of the…

5953. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60172/psn-pdf
      March 01, 2021 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart Originally published on June 12, 2020 Last updated on January 11, 2021 https://psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly- reduc…

5954. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49798/psn-pdf
      July 01, 2017 - Pseudo-obstruction But a Real Perforation July 1, 2017 Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation Case Objectives Recognize acute colonic pseudo-obstruction and implement a medical management plan. Ide…

5955. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33849/psn-pdf
      January 01, 2018 - In Conversation With… Robert Hirschtick, MD January 1, 2018 In Conversation With… Robert Hirschtick, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md Editor's note: Dr. Hirschtick is Associate Professor of Medicine at Northwestern Medicine, and the author of a numbe…

5956. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/866984
      January 01, 2020 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Interdisciplinary teamwork Curated Library Foundations Medical teamwork and the evolution of safety science: a critical review. Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22:13-27. In this narrative review, the authors contr…

5957. It's Sarah, Not Stephen! | PSNet
      psnet.ahrq.gov/web-mm/its-sarah-not-stephen
      January 01, 2015 - SPOTLIGHT CASE It's Sarah, Not Stephen! Citation Text: Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…

5958. Code Blue—Where To? | PSNet
      psnet.ahrq.gov/web-mm/code-blue-where
      March 30, 2020 - Code Blue—Where To? Citation Text: Adams BD. Code Blue—Where To?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…

5959. Failure to Rescue | PSNet
      psnet.ahrq.gov/primer/failure-rescue
      September 15, 2024 - Failure to Rescue Citation Text: Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubM…

5960. Root Cause Analysis Gone Wrong | PSNet
      psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
      August 28, 2024 - Root Cause Analysis Gone Wrong Citation Text: Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…