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psnet.ahrq.gov/node/49839/psn-pdf
August 01, 2018 - Mixup Beyond the Medication Label
August 1, 2018
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
The Case
An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another
hospi…
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psnet.ahrq.gov/node/49868/psn-pdf
July 02, 2019 - Delayed Clozapine Prescription in an Elderly Man With
Dementia
July 2, 2019
Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
The Case
An 86-year-old man with neurode…
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hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/or31.jsp
August 01, 2014 - Motor Vehicle Crash Mortality among Northwest AI/AN.
An official website of the Department of Health & Human Services
Search All AHRQ Websites
Careers
Contact Us
Espanol
FAQs…
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hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/or22.jsp
July 01, 2014 - Record Linkage to Enhance STD/HIV Surveillance Data for Oregon's AI/AN Population
An official website of the Department of Health & Human Services
Search All AHRQ Websites
Careers
Contac…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
October 01, 2010 - Spotlight Case July 2008
Spotlight Case October 2010
Dangerous Dialysis
*
*
Source and Credits
This presentation is based on the October 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jean L. Holley, MD, University of Illinois, Urbana-…
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digital.ahrq.gov/sites/default/files/docs/citation/r36hs023057-jackman-final-report-2016.pdf
January 01, 2016 - Use of Electronic Personal Health Records as a Health Risk-Reduction Discussion Tool - Final Report
1
Title: Use of Electronic Personal Health Records as a health risk-reduction discussion tool
(eSHINE Study)
Principal Investigator: Kevon-Mark Jackman, MPH, DrPHc
Morgan State University
Project Dates: Mar…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereport-slides.html
September 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Training
Facilitator Training Slide Presentation
Text version of slide presentation.
Slide 1: Introduction to Preventable Hospital and ED Visits Reports
AHRQ’s Safety Program for Nursing Homes: On-Time …
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hcup-us.ahrq.gov/reports/statbriefs/sb159.pdf
September 01, 2012 - Trends in Rates of Perforated Appendix, 2001–2010
1
July 2013
Trends in Rates of Perforated Appendix,
2001–2010
Marguerite L. Barrett, M.S., Anika L. Hines, Ph.D., M.P.H., and
Roxanne M. Andrews, Ph.D.
Introduction
Monitoring trends in access to and quality of health care is an
important…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/breast-cancer-medications_surveillance.pdf
July 01, 2012 - i
CER # 17:
Comparative Effectiveness of Medications To Reduce Risk of
Primary Breast Cancer in Women
Original release date:
September 14, 2009
Surveillance Report 1st Assessment: November, 2011
Surveillance Report 2nd Assessment: July, 2012
Key Findings:
• 2 of 6 conclusions for Key Question 1, …
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psnet.ahrq.gov/node/854990/psn-pdf
November 01, 2023 - Identifying contributing factors associated with dental
adverse events through a pragmatic electronic health
record-based root cause analysis.
November 1, 2023
Kalenderian E, Bangar S, Yansane A, et al. Identifying contributing factors associated with dental adverse
events through a pragmatic electronic health rec…
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psnet.ahrq.gov/node/47454/psn-pdf
May 29, 2019 - Development and implementation of a subcutaneous
insulin pen label bar code scanning protocol to prevent
wrong-patient insulin pen errors.
May 29, 2019
MacMaster HW, Gonzalez S, Maruoka A, et al. Development and Implementation of a Subcutaneous
Insulin Pen Label Bar Code Scanning Protocol to Prevent Wrong-Patient …
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psnet.ahrq.gov/node/41796/psn-pdf
January 18, 2013 - Retained surgical items: a problem yet to be solved.
January 18, 2013
Stawicki SPA, Moffatt-Bruce SD, Ahmed HM, et al. Retained surgical items: a problem yet to be solved. J
Am Coll Surg. 2013;216(1):15-22. doi:10.1016/j.jamcollsurg.2012.08.026.
https://psnet.ahrq.gov/issue/retained-surgical-items-problem-yet-be-so…
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www.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumpaky.html
October 01, 2014 - Pakyz, Amy
Summaries of Independent Scientist (K) Awards
Summaries of recently funded projects for Independent Scientist and Mentored Clinical Scientist Development K Awards.
Institution: Virginia Commonwealth University, Richmond
Grant Title: Evaluating Clostridium Difficile Infection in Hospitalized…
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psnet.ahrq.gov/node/45317/psn-pdf
August 17, 2016 - Partnered pharmacist charting on admission in the
general medical and emergency short-stay unit—a
cluster-randomised controlled trial in patients with
complex medication regimens.
August 17, 2016
Tong EY, Roman C, Mitra B, et al. Partnered pharmacist charting on admission in the General Medical and
Emergency Shor…
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psnet.ahrq.gov/node/850933/psn-pdf
June 21, 2023 - The prevalence of second victim syndrome and emotional
distress in pediatric intensive care providers.
June 21, 2023
Wolf MS, Smith K, Basu M, et al. The prevalence of second victim syndrome and emotional distress in
pediatric intensive care providers. J Pediatr Intensive Care. 2023;12(02):125-130. doi:10.1055/s-00…
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psnet.ahrq.gov/node/46610/psn-pdf
December 06, 2017 - Pragmatic insights on patient safety priorities and
intervention strategies in ambulatory settings.
December 6, 2017
Sarkar U, McDonald KM, Motala A, et al. Pragmatic Insights on Patient Safety Priorities and Intervention
Strategies in Ambulatory Settings. Jt Comm J Qual Patient Saf. 2017;43(12):661-670.
doi:10.10…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops101-2-brady-2018.pdf
January 01, 2018 - Understanding SOPS Surveys: A Primer for New Users - Brady
6
Overview of AHRQ’s Patient Safety
Priorities and Programs
Jeff Brady, MD, MPH
Director, Center for Quality Improvement and Patient Safety,
Agency for Healthcare Research and Quality (AHRQ)
Rear Admiral, Assistant Surgeon General, U.S. Public Health Ser…
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www.ahrq.gov/evidencenow/projects/urinary/resources/preventing-voltage-drop.html
January 01, 2014 - Back to MUI Resources
Preventing the Voltage Drop: Keeping Practice-Based Research Network (PBRN) Practices Engaged in Studies
Resource
Full Article on PubMed.
Summary
Practice-based research continues to evolve and has become a major methodology for many pragmatic studies. W…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/umich-slides.ppt
May 20, 2012 - HHCEB Presentation
*
VTE Prevention:
An Institution-wide Initiative
University of Michigan
Caprini VTE risk assessment
May 20, 2012
Marc Moote, PA-C
Chief Physician Assistant
University of Michigan Health System
*
*
Key Strategies
Scope: ALL adult inpatients
Standardized VTE Protocol – Caprini model
Mandato…
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www.ahrq.gov/talkingquality/translate/compare/choose/standard.html
January 01, 2023 - Comparing Quality Scores to an Independent Standard
Another approach would be to compare scores to an independent standard of what performance on this measure ideally should be . While implementing this approach is challenging, it has significant advantages.
Advantages of Comparing to an Independent Standard…