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9921. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73549/psn-pdf
      July 28, 2021 - Local Anesthesia-Induced Coma During Total Knee Arthroplasty. July 28, 2021 Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty The Case A 61-year-old male patient weighing 57…

9922. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.278_slideshow.ppt
      September 01, 2012 - Spotlight Case July 2008 Spotlight Case Peripheral IV in Too Long 1 2 Source and Credits This presentation is based on the September 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Chi-Tai Fang, MD, PhD; Associate Professor, National Taiwan Uni…

9923. Gap Analysis for Antibiotic Stewardhip in Ambulatory Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/gap-analysis-tool.pdf
      September 01, 2022 - Gap Analysis for Antibiotic Stewardhip in Ambulatory Care AHRQ Safety Program for Improving Antibiotic Use Gap Analysis for Antibiotic Stewardship in Ambulatory Care Instructions: Complete this document to evaluate the practices antibiotic stewardship activities on an annual basis and to define areas …

9924. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865467/psn-pdf
      March 27, 2024 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences March 27, 2024 Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferenc…

9925. Pf-Engagement-Facilitator-Guide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docx
      May 01, 2017 - AHRQ Safety Program for Perinatal Care Engage Patients and Families for Perinatal Safety Engage Patients and Families for Perinatal Safety SAY: The Patient and Family Engagement module focuses on an important topic: making sure patients and their family members understand what is happening during the patient’s hospi…

9926. Antibiotic Audit Tool | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/tools/surgical-complication-prevention/antibiotic-audit.html
      December 01, 2017 - Antibiotic Audit Tool AHRQ Safety Program for Surgery Introduction Problem Statement Perioperative antimicrobial prophylaxis is an important strategy to prevent surgical site infection.  Appropriate selection, dosing, and redosing ensure that the antibiotic concentration in surgical site tis…

9927. The LifePoint National Quality Program Provides Structured Framework for Reducing Inpatient Harm | PSNet
      psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-reducing-inpatient-harm
      February 26, 2025 - The LifePoint National Quality Program Provides Structured Framework for Reducing Inpatient Harm Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL January 5, 2021 Innovation Contact …

9928. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49785/psn-pdf
      February 01, 2017 - Refused Medication Error February 1, 2017 Foley M. Refused Medication Error. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/refused-medication-error The Case A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was alert to self and place only. The patient h…

9929. Improving Antibiotic Use is a Patient Safety Issue
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/implementing-stewardship-slides.pptx
      September 01, 2022 - Improving Antibiotic Use is a Patient Safety Issue AHRQ Safety Program for Improving Antibiotic Use Implementing Antibiotic Stewardship in Your Practice Ambulatory Care AHRQ Pub. No. 17(22)-0030 September 2022 Implementing Stewardship AHRQ Safety Program for Improving Antibiotic Use – Ambulatory Care 1 Objecti…

9930. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33633/psn-pdf
      May 01, 2006 - Patient Safety in the Physician Office Setting May 1, 2006 Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/patient-safety-physician-office-setting Perspective Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 …

9931. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49796/psn-pdf
      June 01, 2017 - Chest Tube Complications June 1, 2017 Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/chest-tube-complications The Case A 30-year-old woman with a history of cystic fibrosis was admitted to the hospital for management of a spontaneous left pneumothorax (coll…

9932. Teaching Implementation Change Management | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/team/implement/teach-change.html
      February 01, 2024 - Teaching Implementation Change Management Change Management Overview and Objectives Display Slide 63, “Change Management,” as the class reassembles before discussing the last implementation topic. In discussing Slide 64, “Objectives,” as you transition from coaching to change management, note that succe…

9933. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49572/psn-pdf
      October 01, 2008 - Mistaken Identity October 1, 2008 Hall LW. Mistaken Identity. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/mistaken-identity The Case An 85-year-old Cantonese-speaking woman was admitted to the medical service with altered mental status and a reported fall. After finding tenderness in her left hip, the p…

9934. Slide 1
      effectivehealthcare.ahrq.gov/sites/default/files/selection-of-data-sources-chapter-8.pptx
      January 01, 2013 - The observational research designs that often require primary data collection are described below: Prospective … The observational research designs that require primary data collection are described here. … Registries use an observational study design that does not specify treatments or require therapies intended … Creating the best definitions for key variables may require the involvement of knowledgeable clinicians … One strategy to increase the availability of PROs in clinical care is to require it for compliance with

9935. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45957/psn-pdf
      August 15, 2018 - The authors conclude that trainees do not require attending supervision to safely perform appendectomies

9936. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38961/psn-pdf
      September 01, 2016 - potential of computerized provider order entry (CPOE) systems to prevent potentially harmful errors may require

9937. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39176/psn-pdf
      December 16, 2009 - Though not formally requiring a rapid response system, The Joint Commission does require that all hospitals

9938. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41337/psn-pdf
      May 29, 2012 - be particularly vulnerable to errors due to the complex, multidisciplinary nature of the care they require

9939. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40819/psn-pdf
      January 07, 2015 - Drug administration errors are a major safety concern in anesthesiology, as even routine cases can require

9940. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42023/psn-pdf
      May 25, 2013 - Cases flagged by triggers also require more detailed chart reviews, which may not be feasible for institutions