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  1. Grand Rounds Presentation | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
    August 01, 2022 - Grand Rounds Presentation AHRQ Communication and Optimal Resolution Toolkit Say: This presentation will introduce you to Communication and Optimal Resolution, or the CANDOR process. Some organizations struggle to improve the way they and their care teams respond to medical harm. The CANDOR process a…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863308/psn-pdf
    February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy February 28, 2024 Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy The Case A…

  3. 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…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49758/psn-pdf
    April 01, 2016 - Dropping to New Lows April 1, 2016 Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/dropping-new-lows Case Objectives State how to manage diabetes medications when patients are admitted to the hospital Describe a guideline-recommended insulin regimen for a hospitaliz…

  5. Final Progress Report: Rural Healthcare Quality Network (RHQN) – AHRQ Grant Pre-Intervention Study Results (pdf file)

    www.ahrq.gov/sites/default/files/2024-07/huck-report.pdf
    January 01, 2024 - Final Progress Report: Rural Healthcare Quality Network (RHQN) – AHRQ Grant Pre-Intervention Study Results Rural Healthcare Quality Network (RHQN) – Agency for Healthcare Research and Quality Grant FINAL REPORT BACKGROUND Purpose of the Study The purpose of the study was to examine clinician’s attitudes and p…

  6. Using Data To Drive Change and Improve Patient Safety Facilitator Notes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/data-change-notes.docx
    April 01, 2022 - Using Data To Drive Change and Improve Patient Safety Facilitator Notes CUSP Module: Using Data To Drive Change and Improve Patient Safety Facilitator Guide Slide Number and Image This module, “Using Data To Drive Change and Improve Patient Safety” is part of the Agency for Healthcare Research and Quality, or A…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33734/psn-pdf
    August 01, 2012 - In Conversation With… Nicholas G. Castle, MHA, PhD August 1, 2012 In Conversation With… Nicholas G. Castle, MHA, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd Editor's note: The topic of patient safety in long-term care facilities has not received the attent…

  8. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. | PSNet

    psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
    October 31, 2023 - SPOTLIGHT CASE Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. Citation Text: Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.. PSNet [internet]. Rockville (MD):…

  9. Chapter 7. Layering Interventions and Moving Toward Excellence | Agency for Healthcare Research and Quality

    www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide7.html
    May 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism Chapter 7. Layering Interventions and Moving Toward Excellence Previous Page Next Page Table of Contents Preventing Hospital-Associated Venous Thromboembolism Preface Executive Summary Chapter 1. The Framework for Improvement Chapter 2. A…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862983/psn-pdf
    February 28, 2024 - Airway Obstruction during Anterior Cervical Spine Surgery February 28, 2024 Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery The Case A 47-year-old obese man (body weight 13…

  11. Patient Safety in the Ambulatory Care Setting | PSNet

    psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
    April 27, 2022 - Annual Perspective Patient Safety in the Ambulatory Care Setting August 5, 2022  View more articles from the same authors. Citation Text: Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet]. Rockville (MD): …

  12. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest | PSNet

    psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
    April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest Citation Text: Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. Rockvil…

  13. Chapter 7. Layering Interventions and Moving Toward Excellence | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide7.html
    May 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism Chapter 7. Layering Interventions and Moving Toward Excellence Previous Page Next Page Table of Contents Preventing Hospital-Associated Venous Thromboembolism Preface Executive Summary Chapter 1. The Framework for Improvement Chapter 2. A…

  14. Evaluating Smart Forms and Quality Dashboards in an Electronic Health Record (EHR) | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/evaluating-smart-forms-and-quality-dashboards-electronic-health-record-ehr
    January 01, 2023 - Evaluating Smart Forms and Quality Dashboards in an Electronic Health Record (EHR) Project Final Report ( PDF , 86.44 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily …

  15. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia | PSNet

    psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
    January 29, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia Citation Text: Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and…

  16. Meeting Minutes, November 2019 | Agency for Healthcare Research and Quality

    www.ahrq.gov/news/events/nac/2019-11-nac/nacmtg01121-minutes.html
    March 01, 2020 - Meeting Minutes, November 2019 Minutes from the November 21, 2019, meeting of the Agency for Healthcare Research and Quality's National Advisory Council. Contents Summary Call to Order and Approval of July 24, 2019, Meeting Summary AHRQ Accomplishments Budget Update Challenges and Opportunities To L…

  17. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy | PSNet

    psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
    March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy Citation Text: Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…

  18. Delay in Malignancy Diagnosis Reflects Systemic Failures | PSNet

    psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
    September 25, 2019 - Delay in Malignancy Diagnosis Reflects Systemic Failures Citation Text: Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: …

  19. Statistical Brief #77: Payers of Emergency Department Care, 2006 (pdf file)

    hcup-us.ahrq.gov/reports/statbriefs/sb77.pdf
    July 01, 2009 - Statistical Brief #77: Payers of Emergency Department Care, 2006 HEALTHCARE COST AND UTILIZATION PROJECT Agency for Healthcare Research and Quality STATISTICAL BRIEF #77 July 2009 Payers of Emergency Department Care, 2006 Pamela L. Owens, Ph.D. and Ryan Mutter, Ph.D. Introduction …

  20. Statistical Brief #32: Hospital Admissions That Began in the Emergency Department for Children and Adolescents, 2004 (pdf file)

    hcup-us.ahrq.gov/reports/statbriefs/sb32.pdf
    June 01, 2007 - Statistical Brief #32: Hospital Admissions That Began in the Emergency Department for Children and Adolescents, 2004 HEALTHCARE COST AND UTILIZATION PROJECT Agen Res June 2007 In 200 million childre under births cents) Relati each adole were m hospit pared The g low-in aid, b of hos…
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