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6541. Final Progress Report: Individualized Performance Feedback on Venous Thromboembolism Prevention Practice (pdf file)
      www.ahrq.gov/sites/default/files/2025-06/haut-report.pdf
      January 01, 2025 - VTE using the validated AHRQ Patient Safety Indicator-12, and determine the proportion of patients … Conclusions Overall, venous thromboembolism remains a major patient safety risk in hospitalized patients … The top patient safety strategies that can be encouraged for adoption now. … In: In "Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety … Patient Safety and Quality Improvement Adaptation During the COVID-19 Pandemic.

6542. Statistical Brief #132
      hcup-us.ahrq.gov/reports/statbriefs/sb132.jsp
      May 01, 2012 - Variables for Revisit Analyses American Hospital Association (AHA) Linkage Files AHRQ Quality Indicators … There were no significant differences in pediatric cancer hospitalization rates by patient residence … The income quartile is missing for homeless and foreign patients. … Medicaid includes fee-for-service and managed care Medicaid patients. … safety, and the impact of health policy changes.

6543. Statistical Brief #138
      hcup-us.ahrq.gov/reports/statbriefs/sb138.jsp
      July 01, 2012 - Variables for Revisit Analyses American Hospital Association (AHA) Linkage Files AHRQ Quality Indicators … Characteristics of stays such as patient age, sex, expected payer, and geographic differences are examined … The income quartile is missing for homeless and foreign patients. … Medicaid: includes fee-for-service and managed care Medicaid patients. … safety, and the impact of health policy changes.

6544. Final Progress Report: Challenges and Opportunities for Stewardship of Urological Imaging (pdf file)
      www.ahrq.gov/sites/default/files/2025-05/nielsen2-report.pdf
      January 01, 2025 - Presenters Timothy Averch, MD; AUA Quality Improvement and Patient Safety Committee Chair; University … Nielsen, MD, MS, FACS; Quality Improvement Summit Chair, AUA Quality Improvement and  Patient Safety …  recurrent disease), there are numerous opportunities  to enhance quality, value, and patient safety. … Informing patients of their cumulative dose exposure may  have an impact on patient demand for tests  … Closing Remarks Timothy Averch, MD, AUA Quality Improvement and Patient Safety Committee Chair; University

6545. Final Progress Report: Challenges and Opportunities for Stewardship of Urological Imaging (pdf file)
      www.ahrq.gov/sites/default/files/2025-04/nielsen-report.pdf
      January 01, 2025 - Presenters Timothy Averch, MD; AUA Quality Improvement and Patient Safety Committee Chair; University … Nielsen, MD, MS, FACS; Quality Improvement Summit Chair, AUA Quality Improvement and  Patient Safety …  recurrent disease), there are numerous opportunities  to enhance quality, value, and patient safety. … Informing patients of their cumulative dose exposure may  have an impact on patient demand for tests  … Closing Remarks Timothy Averch, MD, AUA Quality Improvement and Patient Safety Committee Chair; University

6546. Improving Post-Hospital Medication Management of Older Adults with Health Information Technology | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/improving-post-hospital-medication-management-older-adults-health-information
      January 01, 2023 - Completed Grant Number R18 HS017203 Funding Mechanism(s) Ambulatory Safety … Primary Care Health Care Theme Adverse Events Medication Management Medication Safety … Multiple factors, including poor physician-patient communication and education regarding medication use … During care transitions, patients receive medications from different prescribers who often lack access … to patients’ comprehensive medication lists.

6547. Health Information Technology in the Nursing Home - 2008 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/health-information-technology-nursing-home/annual-summary/2008
      January 01, 2008 - Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety … Impact and Findings: A CDSS in the long-term care setting can lead to improved medication safety, but … Nursing time devoted to medication administration in long-term care: clinical, safety, and resource implications … developing and implementing a computerized clinical decision support system for medication dosing for patients

6548. In Conversation With… Rebecca Smith-Bindman, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-rebecca-smith-bindman-md
      October 01, 2013 - She is a national leader in the impact of radiologic testing on patient outcomes, and in the safety—particularly … The 400 or so patients who underwent those CTs—some were older patients who had strokes or were suspected … , bringing radiation safety under the broad umbrella of the patient safety field. … Instead, the patient needs to be informed. … Safety February 26, 2025 Patient Safety Innovations

6549. AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Enhancing Healthcare Facility Design (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hcfd-rev.pdf
      November 01, 2023 - AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Enhancing Healthcare Facility … Design 1 PATIENT SAFETY AHRQ-Funded Patient Safety Project Highlights Improving Healthcare Safety … Safety: Developing Methods To Integrate Patient Safety Concerns Into the Facility Design Process … Safety, and a seminar focused on design for patient safety. … /settings/hospital/resource/safety-assess.html https://www.ahrq.gov/patient-safety/settings/hospital/

6550. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization | PSNet
      psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
      September 01, 2012 - If patient safety is jeopardized at any point, all team members should feel free to voice their concern … safety: the Singapore experience. … February 22, 2023 Epidemiology, patterns of care, and mortality for patients with acute … March 9, 2016 A tool for the concise analysis of patient safety incidents. … October 18, 2023 Radiographers' experience of preventing patient safety incidents in

6551. Best Practices in the Diagnosis and Treatment of Bacteremia
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/bacteremia-slides.pptx
      November 01, 2019 - for Improving Antibiotic Use – Acute Care The Four Moments of Antibiotic Decision Making Does my patient … has an appropriate clinical response Appropriate source control preferred Patient needs to be able to … should receive TEE15 Patients at low risk for endocarditis in whom short-course therapy is desired Patient … defervesces within 72 hours of initiating effective therapy Patient has no localizing signs or symptoms … Effect and safety of meropenem-vaborbactam versus best-available therapy in patients with carbapenem-resistant

6552. Making a Case for Organizational Change in Patient Safety Initiatives (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Ramanujam.pdf
      January 01, 2003 - Change in Patient Safety Initiatives Rangaraj Ramanujam, Donna J. … may be unaware of the extent to which patients are exposed to errors. … for improving patient safety. … Inevitable frustration of patient safety champions. … safety, the logic of organizational change must start to drive patient safety initiatives.

6553. Patient Safety Amid Nursing Workforce Challenges | PSNet
      psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
      April 24, 2024 - Patient Safety Amid Nursing Workforce Challenges . PSNet [internet]. … Patient Safety Amid Nursing Workforce Challenges . PSNet [internet]. … Specifically, having fewer nurses caring for patients is associated with higher patient mortality. … safety—namely, that more effective teamwork and communication mitigate patient safety risks. … Nurse-patient ratios as a patient safety strategy: a systematic review.

6554. Radiology Missed an Intracranial Bleed in a Lethargic Infant. | PSNet
      psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
      August 21, 2016 - In fact, abused patients often have a delayed presentation. … Approach to Improving Safety Get a Head CT First for Evaluation of Possible AHT In this case, an ultrafast … Radiologic head CT interpretation errors in pediatric abusive and non-abusive head trauma patients. … Safety October 1, 2017 WebM&M Cases When the … safety in the hospital: a mixed methods study.

6555. Participant Recruitment for Research | Digital Healthcare Research
      digital.ahrq.gov/participant-recruitment-research
      January 01, 2023 - one-on-one discussions with AHRQ health information technology (IT) grantees funded under the Ambulatory Safety … indicated that they had challenges recruiting patient participants into their projects.  … to patient locations instead of requiring them to travel.  … This "person of trust" builds a connection between patients and the project team.  … AHRQ health IT grantees funded under the Ambulatory Safety and Quality Program involved in patient recruitment

6556. Systematic Review on Opioid Treatments for Chronic Pain: Surveillance Report 1 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/opioids-chronic-pain-surveillance-report-1-final.pdf
      April 01, 2022 - Patient outcomes following opioid dose reduction among patients with chronic opioid therapy. … Patient outcomes following opioid dose reduction among patients with chronic opioid therapy. … Predicting opioid therapy safety in pancreatic cancer patients. … Patient reported outcomes and neuropsychological testing in patients with chronic non-cancer pain in … Efficacy and safety of morphine hydrochloride in cancer patients with chronic pain.

6557. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49654/psn-pdf
      June 01, 2012 - The Commentary The quality and safety of patient transportation, whether it be for non-emergent or critically … Institutions should learn from this case and continue to improve the quality and safety of care patients … Transporting patients entails inherent safety risks. … Which patients and where: a qualitative study of patient transfers from community hospitals. … Non-emergency patient transport: what are the quality and safety issues? A systematic review.

6558. Evidence-based Practice Center Systematic Review Protocol (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/preterm-birth-terbutaline-pump_disposition-comments.pdf
      September 01, 2011 - “In addition, the patient herself could administer 0.25 mL twice daily if increased uterine activity … Peer Reviewer 4 KQ4 (Neonatal Harms) Significant information about the safety of SCT infusion was … 4 KQ6 (incidence of pump Failure) Lastly, many of the articles with good data on efficacy (and safety … As previously noted, the safety data should be bolstered by including the references previously mentioned … Source: www.effectivehealthcare.ahrq.gov 12 helpful in the appropriate patient as well as to

6559. Decision Making and Clinical Work of Test Result Followup in Health Information Technology Settings | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/decision-making-and-clinical-work-test-result-followup-health-information
      January 01, 2023 - Safety Sociotechnical Aspects A significant number of patients with abnormal test results … ' experiences related to diagnostic errors is essential for progress in patient safety. … Learning from patients' experiences related to diagnostic errors is essential for progress in patient … safety. … Challenges in patient safety improvement research in the era of electronic health records.

6560. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49540/psn-pdf
      August 21, 2007 - The patient was ultimately stabilized and transferred to the cardiac intensive care unit. … crucial need to strictly follow checklist procedures and must be motivated to embrace a culture of safety … Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital … Indicators/ECG Display    a. Power "on"    b. Self test ok    c. Monitor display functional    d. … Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital