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psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - The surgeon and anesthesiologist assumed the patient’s apnea was due to opiate sensitivity and assisted
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psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
January 29, 2021 - A thorough preoperative assessment should also be performed by the surgeon in the patient’s own language
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Learning From Defects
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
Slide Title and Commentary
Slide Number and Slide
Learning From Defects
SAY:
Welcome to this presentation on Learning From Defects as part of an o…
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psnet.ahrq.gov/node/60721/psn-pdf
July 21, 2020 - Neri Cohen, a Cardiovascular and Thoracic Surgeon and informaticist. In this role, Dr. … An orthopedic surgeon
has to be able to examine your knee to figure out your restriction to motion and … A general surgeon
has to be able to examine you to get a literal feel for your hernia.
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effectivehealthcare.ahrq.gov/sites/default/files/pregnancy_hi_impact.pdf
January 01, 2012 - A pediatric surgeon removes the protruding
myelomeningocele sac and closes the tissue around it including … A prescription is needed for the milk to be dispensed.
23
According to
the 2011 Surgeon General’s … A pediatric surgeon removes the protruding myelomeningocele sac and closes the tissue around it
including … Office of the Surgeon General. … The Surgeon
General's call to action to support breastfeeding:
fact sheet. [internet].
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digital.ahrq.gov/sites/default/files/docs/citation/AppendixE_HIT_Hazard_Manager_Beta_Test.pdf
June 16, 2021 - A surgeon came in the next morning and ordered a Computed
Tomography (CT) scan for a patient with a … later that morning, a nurse realized that the
problem was with the ICP calculation and warned the surgeon
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
January 01, 2014 - The surgeon gave her an immediate and sensitive apology for the error, accepting full responsibility. … But no one offered her compensation, beyond the surgeon waiving his portion of the bill.
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psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph
March 01, 2014 - People are much more concerned about health care–associated infections than whether the surgeon will … important that the organization that you work in completely backs this up, so there can be no physician or surgeon
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/089-or-traffic-fg.docx
April 01, 2025 - .
· Ensure that surgeon preferences cards are complete to have all supplies stocked in OR in advance
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www.ahrq.gov/sites/default/files/2025-05/fraser-dunagan-report.pdf
January 01, 2025 - Final Progress Report: Improving Patient Safety: Health Systems Reporting, Analysis and Safety Improvement Research Demonstrations
1
Title: Improving Patient Safety: Health Systems Reporting, Analysis and Safety
Improvement Research Demonstrations
Principal Investigator: Victoria J. Fraser, MD
Co-Principal Inv…
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effectivehealthcare.ahrq.gov/sites/default/files/assessing-applicability.ppt
January 01, 2009 - Assessing Applicability
Assessing Applicability
Agency for Healthcare Research and Quality (AHRQ)
Training Modules for Methods Guide for Effectiveness and Comparative Effectiveness Reviews
Assessing Applicability
Systematic Review Process Overview
*
Systematic Review Process Overview
This slide illustrates th…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Baker.pdf
February 01, 2005 - who role-plays the circulating nurse and an
anesthesiologist instructor who role-plays the operating surgeon … In 2001, the Air Force Surgeon General mandated MTM training for all high-
risk specialties: emergency
-
hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/ca9.pdf
June 16, 2014 - Understanding Drivers of Health Care Disparities and Developing Targeted Interventions
Northwestern University Feinberg School of Medicine
Understanding Drivers of Health Care Disparities
and Developing Targeted Interventions
Romana Hasnain-Wynia, PhD
Director, Center for health care Equity
Associate Professo…
-
www.ahrq.gov/hai/tools/surgery/tools/surgical-complication-prevention/glucose-control-factsheet.html
December 01, 2017 - Glucose Control Factsheet
AHRQ Safety Program for Surgery
Facts About Glucose Control and the Prevention of Surgical Site Infections
Definition of Tight Glucose Control
Tight glucose control refers to getting as close to a normal (nondiabetic) blood glucose level as you safely can. Ideally, th…
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www.ahrq.gov/news/newsletters/e-newsletter/927.html
August 01, 2024 - AHRQ-Funded Research Highlights Impact of Private Equity in Healthcare
Issue Number
927
AHRQ News Now is a weekly newsletter that highlights agency research and program activities.
August 27, 2024
AHRQ Stats: Cost and Billing Trends for Sepsis-Related Stays Since 2016, aggregate hospital costs for sepsi…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4i_pdi11-dehiscence-bestpractices.pdf
May 17, 2016 - Selected Best Practices and Suggestions for Improvement
Pediatric Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4i
Selected Best Practices and Suggestions for Improvement
PDI 11: Postoperative Wound Dehiscence
Why focus on postoperative wound dehiscence in…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/standalone_pdi_casestudy.pdf
December 01, 2015 - Children’s Hospital Uses AHRQ’s Pediatric QI Toolkit To Bring Physicians Together To Reduce CLABSIs
Children’s Hospital Uses AHRQ’s Pediatric QI Toolkit To Bring
Physicians Together To Reduce CLABSIs
Abstract
The Ann & Robert H. Lurie Children’s Hospital
used the tools from the Pediatric QI Toolkit – which …
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/4-ASC_Webcast_2021-Famolaro.pdf
January 01, 2021 - How to Use the AHRQ SOPS Ambulatory Surgery Center Survey to Improve Patient Safety - Famolaro
SOPS ASC Database and Resources
20
Theresa Famolaro, MPS, MS, MBA
Senior Study Director
User Network for the AHRQ Surveys on Patient Safety Culture (SOPS)
Westat
SOPS Databases
21
Hospital Nursing
Home
Medical
Of…
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digital.ahrq.gov/ahrq-funded-projects/implementing-breast-reconstruction-decision-support-tool-diverse-practice
January 01, 2024 - Implementing a Breast Reconstruction Decision Support Tool in Diverse Practice Settings
Project Final Report ( PDF , 830.66 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 necessa…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4m_combo_psi18-19-obstetriclaceration-bestpractices.pdf
May 20, 2016 - Selected Best Practices and Suggestions for Improvement
Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4m
Selected Best Practices and Suggestions for Improvement
PSI 18 and 19: Obstetric Trauma Rate – Vaginal Delivery With and Without Instrument
Why Focus o…