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3321. Final Progress Report: Utility of Predictive Systems in Diagnostic Errors (UPSIDE) (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/auerbach-report.pdf
      January 01, 2025 - This study did three things: Aim 1: We looked at how many diagnostic errors happen among patients who

3322. Missed Nursing Care: A Key Measure for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
      March 01, 2018 - These papers focused on things you could not change such as ownership (whether for profit or nonprofit

3323. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case | PSNet
      psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
      October 02, 2013 - Availability The disposition to judge things as being more likely or frequently occurring, if they

3324. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866370/psn-pdf
      July 31, 2024 - It will be obvious if the patient truly remembers things that happened during the procedure.

3325. AHRQ EvidenceNOW: Building State Capacity: Interim Evaluation Report I (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/building-capacity/en-bsc-interim-report-1.pdf
      January 31, 2024 - One participant explained: “We’re just learning some things about just some red tape that academia has … We’re trying to take care of our patients and trying to facilitate all of these different things that

3326. Suicidal Ideation in the Family Medicine Clinic | PSNet
      psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
      October 01, 2007 - SPOTLIGHT CASE Suicidal Ideation in the Family Medicine Clinic Citation Text: Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: …

3327. Delirium or Dementia? | PSNet
      psnet.ahrq.gov/web-mm/delirium-or-dementia
      September 27, 2023 - SPOTLIGHT CASE Delirium or Dementia? Citation Text: Rudolph JL. Delirium or Dementia?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…

3328. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49801/psn-pdf
      August 01, 2017 - Despite Clues, Failed to Rescue August 1, 2017 Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue Case Objectives Define failure to rescue. Identify the main contributors to failure-to-rescue events. Appreciate the ongoing areas of scien…

3329. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72589/psn-pdf
      December 23, 2020 - Delayed Breast Cancer Diagnosis: A False Sense of Security. December 23, 2020 Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security The Case A 60-year-old woman was se…

3330. Final Progress Report: Reducing Risks by Engineering Resilience Into HIT for EDs (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/wears-report.pdf
      January 01, 2024 - Final Progress Report: Reducing Risks by Engineering Resilience Into HIT for EDs Reducing Risks by Engineering Resilience into HIT for EDs Principal Investigator: Robert L. Wears, MD, MS, PhD Team Members: John Wreathall Rollin (Terry) Fairbanks, MD, MS Ann M. Bisantz, PhD Shawna J Perry, MD Chris Johnson,…

3331. Hand Hygiene
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/infection-prevention/hand-hygiene/hand-hygiene.pptx
      March 01, 2017 - Hand Hygiene The How-To’s of Hand Hygiene Training Module 1 AHRQ Pub. No. 16(17)-0003-8-EF March 2017 AHRQ Safety Program for Long-term Care: HAIs/CAUTI AHRQ Safety Program for Long-Term Care: HAIs/CAUTI AHRQ SAFETY PROGRAM FOR LONG-TERM CARE: HAIs/CAUTI Welcome to the first training module for the Agency for H…

3332. Key Themes Across Grants | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/research-transform-primary-care/transform/synthesis-report/themes.html
      October 01, 2015 - Findings From the AHRQ Transforming Primary Care Grant Initiative: A Synthesis Report Key Themes Across Grants Previous Page Next Page Table of Contents Findings From the AHRQ Transforming Primary Care Grant Initiative: A Synthesis Report Executive Summary Introduction Methods Overview of th…

3333. Delayed Breast Cancer Diagnosis: A False Sense of Security. | PSNet
      psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
      May 01, 2005 - Delayed Breast Cancer Diagnosis: A False Sense of Security. Citation Text: Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Cita…

3334. 011-Ss-Decolonization-Strategies-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/011-ss-decolonization-strategies-fg.docx
      April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI Decolonization Strategies Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries Slide Title and Commentary Slide Number and Slide Decolonization Strategies SAY: Hello. Welcome to this presentation on decolonization strateg…

3335. Final Progress Report: Automated Image Analysis for the Prevention of Radiotherapy Delivery Errors (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/lamb-report.pdf
      January 01, 2024 - Final Progress Report: Automated Image Analysis for the Prevention of Radiotherapy Delivery Errors Final Report: Automated Image Analysis for the Prevention of Radiotherapy Delivery Errors Resubmission Date 1-10-2024 Title of Project: Automated I…

3336. Key Themes Across Grants | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/reports/grants-transform/key-themes.html
      March 01, 2017 - Findings From the AHRQ Transforming Primary Care Grant Initiative: A Synthesis Report Key Themes Across Grants Previous Page Next Page Table of Contents Findings From the AHRQ Transforming Primary Care Grant Initiative: A Synthesis Report Executive Summary Introduction Methods Overview of th…

3337. Disposition of Comments for CER 178 Newer Medications for Lower Urinary Tract Symptoms (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/prostatic-hyperplasia-medications_disposition-comments.pdf
      May 26, 2016 - TEP Reviewer #2 Results I also found it confusing for the authors to say things like "Vardenafil improved

3338. Implementation Guide: Toolkit for MRSA Prevention in ICU & Non-ICU Settings (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/123-mrsa-toolkit-implementation-guide.docx
      October 01, 2024 - Before launching your intervention, your team brainstorms scenarios, how things could go wrong, and what

3339. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
      April 27, 2022 - Our team made an a priori decision that operationalization of the definition would require 2 things:

3340. HIT Support for Safe Nursing Care (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r01hs015054-keenan-final-report-2008.pdf
      January 01, 2008 - What things are important for all nurses to think about when rating a current NOC (to be sure rating