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1341. 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

1342. "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

1343. 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

1344. 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,

1345. 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

1346. 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

1347. Statistical Brief #129
      hcup-us.ahrq.gov/reports/statbriefs/sb129.jsp
      April 01, 2012 - Privacy Notice , Viewers & Players Last modified 4/17/12 Back to Top

1348. 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

1349. 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

1350. Clinical Decision Support for Mild Traumatic Brain Injury - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/k08hs021271-melnick-final-report-2018.pdf
      January 01, 2018 - reassured patients by providing structure to the clinical conversation with cues (eg, How soon can I get back … A key finding was how important it is to teach and emphasize that a concussion is not visible on CT. … Back to the Bedside: Developing a Bedside Aid for Concussion and Brain Injury Decisions in the Emergency

1351. 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

1352. 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

1353. 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

1354. Surgeries in Hospital-Owned Outpatient Facilities, 2012 #188
      hcup-us.ahrq.gov/reports/statbriefs/sb188-Surgeries-Hospital-Outpatient-Facilities-2012.jsp
      February 01, 2015 - Privacy Notice , Viewers & Players Last modified 5/16/16 Back to Top

1355. Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Zierler_81.pdf
      September 01, 2008 - adoption is “an organic and often rather messy model of assimilation in which the organization moves back

1356. Value of Technology to Transfer Discharge Information (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r01hs015084-graumlich-final-report-2007.pdf
      January 01, 2007 - Output from our discharge software went to community physicians via facsimile transmission with back-up

1357. Is Our Pharmacy Meeting Patients' Needs? A Pharmacy Health Literacy Assessment Tool User's Guide (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/pharmlit.pdf
      October 01, 2007 - continually check that they have understood the information we give them by asking them to repeat back … key points (i.e., “teach-back”). 16. … Please hand it back to me when you are finished. Okay, let’s begin! V. … Think back to the first time you went to the pharmacy. How easy or hard was it to find? i. … Has a pharmacist ever asked you to repeat back what she or he told you? ii.

1358. Shared Decision-Making About Screening and Chemoprevention: A Suggested Approach (pdf file)
      www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/inline-files/sharedba.pdf
      January 01, 2004 - Informed decision making in outpatient practice: time to get back to basics.

1359. 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.

1360. AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Enhancing Teamwork and Leadership (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-teamwork-leadership-2025.pdf
      January 01, 2025 - ■ A simulation-based intervention created to teach physicians and nurses about team-based error disclosure … Key Findings/Impact: Researchers designed a simulation-based intervention to teach physicians and nurses