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hcup-us.ahrq.gov/reports/statbriefs/sb277-Top-Reasons-Hospital-Stays-2018.pdf
January 01, 2018 - For example, this information can help establish
national health priorities, initiatives, and action
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Donaldson.pdf
January 01, 2003 - the core course and strategically aligned with
consensually validated organizational and clinical priorities
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/continuing-ed/moc_sms.pdf
March 29, 2016 - Action planning is a collaborative, clinician/patient SMS process to:
• Identify the patient’s health priorities … process for addressing single or multiple chronic conditions by:
• Identifying patient and family priorities … and preferences
• Setting an agenda based on patient priorities and preferences
• Setting goals … Roles include:
• Gathering clinical data and information on patients’ priorities before a visit … • Ask patients about their health priorities and preferences.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/breast-cancer-medications_executive.pdf
September 01, 2009 - Layout 1
Background
Breast cancer is the most frequently
diagnosed noncutaneous cancer and the
second leading cause of cancer death after
lung cancer among women in the United
States. In 2008, an estimated 182,460 cases
of invasive breast cancer and 67,770 cases
of in situ breast cancer were diagnosed, and
40,480 wo…
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psnet.ahrq.gov/node/33703/psn-pdf
November 01, 2010 - Are We Getting Better at Measuring Patient Safety?
November 1, 2010
Rosen AK. Are We Getting Better at Measuring Patient Safety? PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety
Perspective
The past decade has witnessed unprecedented interest in patient safe…
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
1
Source and Credits
This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Elizabeth Gould, NP-C, COR…
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digital.ahrq.gov/sites/default/files/docs/publication/r21hs021581-goodney-final-report-2015.pdf
January 01, 2015 - Leveraging Health Information Technology to Avoid Unnecessary Asymptomatic Carotid Revascularization - Final Report
1. Title Page:
Title: Leveraging Health IT to Avoid Unnecessary Asymptomatic Carotid Revascularization
Principal Investigator: Philip P. Goodney, MD, MS
Organizati…
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Tacit Handover, Overt Mishap
Citation Text:
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
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psnet.ahrq.gov/web-mm/harm-alarm-fatigue
February 14, 2018 - SPOTLIGHT CASE
Harm From Alarm Fatigue
Citation Text:
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 X…
-
psnet.ahrq.gov/web-mm/production-pressures
November 16, 2022 - Production Pressures
Citation Text:
Carayon P. Production Pressures. 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 …
-
psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL Dec Spotlight_Code Status vs Care Status.pptx
Spotlight
Code Status vs. Care Status
Source and Credits
• This presentation is based on the December 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Rebe…
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digital.ahrq.gov/sites/default/files/docs/page/Root.ppt
June 01, 2005 - PowerPoint Presentation
Utah Health Information Network
Jan Root, Ph.D.
Assistant Executive Director
June 2005, AHRQ Annual Meeting
WEDI Fall Conference, November 15-18, 2004
UHIN: CHIN to RHIO
In operation since 1993 (CHIN)
Community-based; inclusive
Providers, payers, gov’t
Statewide network
Not-for-…
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psnet.ahrq.gov/node/857259/psn-pdf
November 30, 2023 - Medication Mix-Up Leads to Patient Death
November 30, 2023
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
The Case
An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…
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www.ahrq.gov/sites/default/files/2024-07/seid-sobo-report.pdf
January 01, 2024 - Final Progress Report: Managing the Health Needs of Vulnerable Children
Title of Project: Managing The Health Needs of Vulnerable Children
Principal Investigator and Team Members: Michael Seid, PhD, Elisa J. Sobo, PhD
Organization: Children’s Hospital Research Center
Inclusive Dates of Project: 9/30/2001 - 9/29/…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Steele_100.pdf
March 18, 2008 - Efficiency Gains with Computerized Provider Order Entry
Efficiency Gains with Computerized
Provider Order Entry
Andrew M. Steele, MD, MPH, MSc; Mical DeBrow, PhD, RN
Abstract
Objective: The objective of this project was to measure efficiency gains in turnaround times
with the implementation of a computer…
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psnet.ahrq.gov/node/73456/psn-pdf
June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult
Intubation and Severe Hypoxemia
June 30, 2021
Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…
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psnet.ahrq.gov/node/49865/psn-pdf
June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy
June 1, 2019
Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
The Case
A 75-year-old man with a past medical history of hemorrhagic stroke, coron…
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psnet.ahrq.gov/node/74251/psn-pdf
January 26, 2022 - Delayed Diagnosis and Treatment of an Occult
Hemothorax Following Complicated Central Line Insertion
Leads to Cardiac Arrest
January 26, 2022
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated
Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. 2022.
https…
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psnet.ahrq.gov/node/33801/psn-pdf
February 01, 2016 - In Conversation With…Christine A. Sinsky, MD
February 1, 2016
In Conversation With…Christine A. Sinsky, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md
Editor's note: Christine A. Sinsky, MD, is the Vice President for Professional Satisfaction at the American
Me…
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www.ahrq.gov/sites/default/files/publications2/files/dx-issue-brief-20-brazil-health-system.pdf
August 01, 2024 - Learning from AHRQ's Diagnostic Safety Culture Survey at a Tertiary Care Health System in Brazil: A Case Study
PATIENT
SAFETY
e
Issue Brief 20
Learning from AHRQs’ Diagnostic Safety
Culture Survey at a Tertiary Care Health
System in Brazil: A Case Study
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e
Issue Brief 2…