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1301. AHRQ Summit to Address Emergency Department Boarding (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/ed-boarding-summit-report.pdf
      March 01, 2025 - Historically, EMS crews could expect to arrive at the ED, transfer their patient, and be back on the … surgeries for people that are high risk or people that are marginalized and more likely to bounce back … ’t have post-surgery, post-medical intervention of some sort—the risk that they’re going to bounce back … procedure are transferred elsewhere for that procedure and then transferred back to the rural hospital … BREAK (Escort Back to Great Hall) 3:50 p.m. – 4:20 p.m.

1302. First Annual Report to Congress on High-Priority Evidence Gaps for Clinical Preventive Services (pdf file)
      www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/inline-files/tfannrpt2011.pdf
      January 01, 2012 - I Low Back Pain: Counseling for Adults The USPSTF concludes that the evidence is insufficient to recommend … for or against the routine use of interventions to prevent low back pain in adults in primary care

1303. Statistical Brief #140
      hcup-us.ahrq.gov/reports/statbriefs/sb140.jsp
      August 01, 2012 - Privacy Notice , Viewers & Players Last modified 9/3/25 Back to Top

1304. Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
      January 01, 2023 - records – Cultural and language barriers with patients – Communication barriers between doctors – Lack of back-up

1305. Module 1: Preventing Pressure Injuries in Hospitals—Understanding Why Change Is Needed | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/guide1.html
      October 01, 2017 - prevention and evolving as needed with the process changes we have gained, but definitely not going back

1306. Meeting Minutes, March 2021 | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/events/nac/2021-03-nac/nacmtg031821-minutes.html
      July 01, 2021 - He encouraged AHRQ to support research that brings the idea of value back to the discussion of, for example

1307. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. | PSNet
      psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
      November 30, 2021 - She was urgently taken back to the OR, where she was found to have necrotizing soft tissue infection,

1308. Syringe Swap During Regional Block: A Case of Medication Error and Recovery | PSNet
      psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
      July 22, 2020 - Upon thorough review, the respiratory distress was traced back to an inadvertent injection of vecuronium

1309. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850361/psn-pdf
      June 14, 2023 - draw attention to the vegetation finding in this case earlier after patient discharge and transfer back

1310. "Do You Want Everything Done?": Clarifying Code Status | PSNet
      psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
      March 27, 2024 - The Case A 63-year-old woman with a history of liver transplantation secondary to hepatitis C, low back

1311. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72517/psn-pdf
      November 25, 2020 - She was urgently taken back to the OR, where she was found to have necrotizing soft tissue infection

1312. Total Parenteral Nutrition, Multifarious Errors | PSNet
      psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
      January 23, 2017 - have a different dose or units than the original order, then the process should stop for clarification back

1313. Impact of Meaningful Use on Clinical Workflow in Emergency Departments - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs022670-patel-final-report-2019.pdf
      January 01, 2019 - area and nurse stations form a tight coupling, i.e. most likely movement for clinicians seems to be back

1314. The Virtual Patient for Improving Quality of Care in Primary Healthcare - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r21hs020323-mollica-final-report-2014.pdf
      January 01, 2014 - Back-end XML-based data are processed in real time via a PhP server. Specific case content (e.g. … measure via email with instructions to provide a case write-up and answer the survey, sending both back

1315. Early Mobility Guide for Reducing Ventilator-Associated Events in Mechanically Ventilated Patients (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-mvpguide.pdf
      January 01, 2017 - Four Es Model Engage Win the hearts and minds of your teams Educate Teach your teams about … Other critical industries, like airlines and nuclear energy, teach us clear principles of safe system … To accomplish this, monitor and report back to your staff each month.

1316. Resource List - AHRQ Nursing Home Survey (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursinghome-resourcelist.pdf
      April 01, 2023 - patient-safety/patientsafetyculture/just-culture.html This website provides links to ways to engage and teach … Part B provides all-inclusive, ready-to-teach, topic-based patient safety courses that can be used as … It includes a fax Cover Sheet, Falls Assessment Report, and Fax Back Orders for the primary care provider

1317. Final Progress Report: Communication to Prevent and Respond to Medical Injuries: WA State Collaborative (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/gallagher1-report.pdf
      January 01, 2024 - , and I have the sense that a lot of people are taking information from the forums and bringing it back … ambitious goal was that we were going to transform communication in healthcare, which, in looking back … patient or family, initiate and carry out a timely investigation of why the injury occurred, feed back … Armstrong assessed barriers to full implementation and reported back to the project team about recommendations … When it came time to begin applying the CRP to events, each site hung back, waiting for another to

1318. Title Page (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015124-selker-final-report-2008.pdf
      January 01, 2008 - System Time Insensitive Predictive Instrument Information System, (EMS TIPI-IS) collected and fed back … Insensitive Predictive Instrument Information System,(EMS TIPI-IS) was created to collect and feed back … and hospital data and patient outcomes was implemented to compile the measures and to regularly feed back … an improvement effort, supported by health information technology, that successfully measured, fed back

1319. Final Progress Report: The National Quality Forum Annual Meeting 2004 (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/kizer2-report.pdf
      January 01, 2025 - The settlement agreement required the hospital to teach others about the possibility of errors from … Disease, Women's Health Screening, Childhood Immunizations, Adult Immunizations, Hypertension, and Low Back … It was sent back to the governance committee for the creation of a full proposal and an assessment … of LI Headings Rule Name Status Description Appropriate nesting Passed Appropriate nesting Back

1320. Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_38.pdf
      March 26, 2008 - Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse…