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4061. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
      January 01, 2022 - Spotlight Spotlight Patient Safety Events Involving Opioid Dose Stacking Source and Credits • This presentation is based on the January 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…

4062. HCUP Facts and Figures 2007: Statistics on Hospital-Based Care in the United States
      hcup-us.ahrq.gov/reports/factsandfigures/2007/sources_methods.jsp
      January 01, 2007 - HCUP Facts and Figures 2007: Statistics on Hospital-Based Care in the United States An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact …

4063. Order Interrupted by Text: Multitasking Mishap | PSNet
      psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
      August 21, 2015 - SPOTLIGHT CASE Order Interrupted by Text: Multitasking Mishap Citation Text: Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: …

4064. In Conversation With… Karl Bilimoria, MD, MS | PSNet
      psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms
      April 19, 2023 - In Conversation With… Karl Bilimoria, MD, MS August 1, 2017  Citation Text: In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation …

4065. Final Progress Report: Factors Associated With Quality of Care Delivered to Children in US EDs (pdf file)
      www.ahrq.gov/sites/default/files/2024-12/marcin-report.pdf
      January 01, 2024 - Final Progress Report: Factors Associated With Quality of Care Delivered to Children in US EDs Factors Associated with Quality of Care Delivered to Children in US EDs PI: James P. Marcin, MD Co-Investigators: Madan Dharmar, MBBS, PhD; Patrick Romano, MD; Nathan Kuppermann, MD, MPH Organization: Regents of the Uni…

4066. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures | PSNet
      psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
      November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures Citation Text: Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …

4067. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49852/psn-pdf
      February 01, 2019 - Triaging Interhospital Transfers February 1, 2019 Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/triaging-interhospital-transfers Case Objectives Recognize that transfer of patients between acute care hospitals is common. Realize that the interhospital transfer…

4068. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49579/psn-pdf
      March 21, 2009 - All in the History March 21, 2009 Fee C. All in the History. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/all-history Case Objectives Describe the Emergency Medical Treatment and Active Labor Act (EMTALA) and understand that it does not apply to transfers to emergency departments from non-acute care faci…

4069. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840174/psn-pdf
      August 28, 2024 - Missed CANDOR Implementation Opportunities. November 16, 2022 Schweitzer L. Missed CANDOR Implementation Opportunities. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities The Case A 58-year-old man with a history of type 2 diabetes mellitus, hypertension, morbid obesit…

4070. AHRQ Safety Program for MRSA Prevention
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/156-what-are-4es.pptx
      October 01, 2024 - AHRQ Safety Program for MRSA Prevention AHRQ Safety Program for MRSA Prevention What Are the 4 Es? ICU/Non-ICU AHRQ Pub. No. 25-0007 October 2024 AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU What Are The Four Es 1 Educational Objectives Define the 4 Es framework—Engage, Educate, Execute, Evaluate—and ex…

4071. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60865/psn-pdf
      August 31, 2020 - In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA- BC-FACHE August 31, 2020 In Conversation With.. Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache Editor’s Note: Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is …

4072. Diabetes | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/nhqrdr/chartbooks/effectivetreatment/diabetes.html
      June 01, 2018 - Chartbook on Effective Treatment Diabetes Previous Page Next Page Table of Contents Chartbook on Effective Treatment Acknowledgments Effective Treatment Effective Treatment Trends and Measures Cardiovascular Disease Cancer Chronic Kidney Disease Diabetes HIV and AIDS Mental Health …

4073. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837660/psn-pdf
      July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse Outcomes July 8, 2022 Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes The Cases Case 1: A 64-year-old man came in for a routine bron…

4074. Final Progress Report: Developing a Risk Index of Healthcare Provider Alertness To Improve Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-10/landrigan3-report.pdf
      January 01, 2024 - Final Progress Report: Developing a Risk Index of Healthcare Provider Alertness To Improve Safety Developing a Risk Index of Healthcare Provider Alertness to Improve Safety Final Progress Report – May 31, 2011 Principal Investigator: Christopher P. Landrigan, M.D., M.P.H. Team Members: Dennis A. Dean, Scott A. …

4075. Optimize Briefings and Debriefings: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/implementation/opt-briefings-slides.html
      December 01, 2017 - Optimize Briefings and Debriefings: Slide Presentation AHRQ Safety Program for Surgery Slide 1: AHRQ Safety Program for Surgery—Implementation Optimize Briefings and Debriefings Slide 2: Learning Objectives Describe characteristics of effective briefings and debriefings. Present the evidence bas…

4076. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49834/psn-pdf
      July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety July 1, 2018 Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety Case Objectives Unders…

4077. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Obstetric Hemorrhage (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_obhemorrhage.docx
      May 01, 2017 - AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Obstetric Hemorrhage AHRQ Safety Program for Perinatal Care Labor and Delivery Unit Safety Obstetric Hemorrhage Labor and Delivery Unit Safety—Obstetric Hemorrhage Purpose of the tool: This tool describes the key perinatal safety elements related t…

4078. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846915/psn-pdf
      March 29, 2023 - Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities. March 29, 2023 Bourgeois JA, Xiong G. Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/challenging-case-multiple…

4079. PSO Program - Common Terms and Acronyms (pdf file)
      pso.ahrq.gov/sites/default/files/wysiwyg/pso-program-acronyms.pdf
      October 01, 2022 - PSO Program - Common Terms and Acronyms Page 1 of 6 PSO PROGRAM: COMMON TERMS AND ACRONYMS [Note: Terms used in the Patient Safety Act or Rule are summarized here solely for convenience and may be defined in the statute or rule. You should always rely on the actual definition when making any determination. The …

4080. Radiology Missed an Intracranial Bleed in a Lethargic Infant. | PSNet
      psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
      August 21, 2016 - Radiology Missed an Intracranial Bleed in a Lethargic Infant. Citation Text: Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation For…