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  1. Evaluating the Effectiveness of a Health Information Technology Self-Management Program for Chronic Disease - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/r21hs021005-sorondo-final-report-2015.pdf
    January 01, 2015 - Evaluating the Effectiveness of a Health Information Technology Self-Management Program for Chronic Disease - Final Report TITLE PAGE Title of Project: Evaluating the Effectiveness of an HIT Self-­‐Management Program for Chronic Disease Patients Principal Investigator and Team Members: PI: Barbara Sorondo,…

  2. Novel IT to Create Patient-Integrated Quality Improvement - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/r21hs024553-bardach-final-report-2018.pdf
    January 01, 2018 - Novel IT to Create Patient-Integrated Quality Improvement - Final Report Title: Novel IT to Create Patient-Integrated Quality Improvement Principal Investigator: Naomi S. Bardach, MD MAS Team Members: Glenn Rosenbluth, MD James A. Wile…

  3. Dangerous Shift | PSNet

    psnet.ahrq.gov/web-mm/dangerous-shift
    July 24, 2013 - SPOTLIGHT CASE Dangerous Shift Citation Text: Patterson ES. Dangerous Shift. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…

  4. EQUIP (Enhancing Quality in Patient Care Utilizing Information Technology in Patient Care) (pdf file)

    digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015354-rachman-final-report-2007.pdf
    January 01, 2007 - EQUIP (Enhancing Quality in Patient Care Utilizing Information Technology in Patient Care) Grant Final Report Grant ID: UC1HS15354 EQUIP (Enhancing Quality in Patient Care Utilizing Information Technology in Patient Care) Inclusive Dates: 09/30/04 - 08/31/07 Principal Investigator: Fred …

  5. Advancing Patient Safety Through State Reporting Systems | PSNet

    psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
    June 01, 2007 - Advancing Patient Safety Through State Reporting Systems Jill Rosenthal, MPH | June 1, 2007  View more articles from the same authors. Citation Text: Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. Rockville (MD): Agency for…

  6. Lost in Transition | PSNet

    psnet.ahrq.gov/web-mm/lost-transition
    November 17, 2010 - SPOTLIGHT CASE Lost in Transition Citation Text: Beach C. Lost in Transition. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

  7. The Missing Abscess: Radiology Reads in the Digital Era | PSNet

    psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
    January 01, 2009 - SPOTLIGHT CASE The Missing Abscess: Radiology Reads in the Digital Era Citation Text: Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837791/psn-pdf
    August 05, 2022 - Patient Safety in the Ambulatory Care Setting August 5, 2022 Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting Introduction There is no way to review the year 2021 in quality and …

  9. Appendix V: Tested Measures by DRA Domain (continued) | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apv2a.html
    June 01, 2010 - Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services Appendix V: Tested Measures by DRA Domain (continued) Previous Page Next Page Table of Contents Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services Executive Summary Introd…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74713/psn-pdf
    January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking January 26, 2022 Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking Disclosure of Relevant Financial Relationships: As a provider ac…

  11. 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…

  12. Duplicate Insulin Order | PSNet

    psnet.ahrq.gov/web-mm/duplicate-insulin-order
    May 04, 2012 - Duplicate Insulin Order Citation Text: Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865455/psn-pdf
    March 27, 2024 - Communication During Transitions of Care March 27, 2024 Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/communication-during-transitions-care Introduction Inaccurate or untimely communication and ineffective teamwork in healthca…

  14. eHHIC: Hospital Engagement (pdf file)

    hcup-us.ahrq.gov/datainnovations/clinicalcontentenhancementtoolkit/hi24.pdf
    September 01, 2013 - eHHIC: Hospital Engagement 1 | P a g e Hawaii Health Information Corporation Enhancing Hawaii Hospital Information Content (eHHIC) Deliverable 1: Hospital Engagement 2 | P a g e TABLE OF CONTENTS I. OBJECTIVE……………………………….………………..…………………………………………3 a. HOSPITAL RECRUITMENT…

  15. Identification of Patients with Low Life Expectancy - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/r01hs024090-turchin-final-report-2019.pdf
    January 01, 2019 - Identification of Patients with Low Life Expectancy - Final Report FINAL PROGRESS REPORT Identification of Patients with Low Life Expectancy Principal Investigator Alexander Turchin, MD, MS1,2 Team M…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50611/psn-pdf
    October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing October 30, 2019 Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing Case Objectives List the most common errors associated with computerized…

  17. A Double “Never Event”: Wrong Patient and Wrong Side. | PSNet

    psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
    August 20, 2018 - A Double “Never Event”: Wrong Patient and Wrong Side. Citation Text: Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49519/psn-pdf
    September 01, 2006 - Triple Handoff September 1, 2006 Vidyarthi A. Triple Handoff. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/triple-handoff Case Objectives Appreciate the prevalence of handoffs and sign out related errors. Understand the key elements of a safe and effective written and verbal sign out. List Kotter’s 8 st…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49811/psn-pdf
    November 01, 2017 - Delayed Diagnosis of Endocrinologic Emergencies November 1, 2017 Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies The Cases Case #1: A 47-year-old man with a history of hyperthyroidism and h…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49675/psn-pdf
    February 01, 2013 - Delay in Treatment: Failure to Contact Patient Leads to Significant Complications February 1, 2013 Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complicat…
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