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Showing results for "veterans affairs".

81. Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri. | PSNet
    psnet.ahrq.gov/issue/deficiencies-inpatient-mental-health-care-coordination-and-processes-prior-patients-death
    May 26, 2021 - Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 5, 2021. … Affairs, Office of Inspector General. … Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 5, 2021. … October 12, 2022 Deficiencies in the Veterans Crisis Line Response to a Veteran Caller … conflicts: review of case reports from a national Veterans Affairs database.

82. Ohio Veterans’ Facility Relied on AHRQ Resource to Develop Diabetes Initiative | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/202301.html
    October 01, 2024 - Ohio Veterans’ Facility Relied on AHRQ Resource to Develop Diabetes Initiative Search All Impact … Case Studies March 2023 The Dayton (Ohio) Veterans Affairs (VA) Medical Center facility has adopted … Department of Veterans Affairs' national Hypoglycemic Safety Initiative to help high-risk diabetes patients … “About half of our veterans with diabetes—around 500 patients—are at high risk for hypoglycemia,” said … Departments of Veterans Affairs and Defense recognized the important role shared decision making plays

83. Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine drug screening and opioid-patient suicide- and overdose-related events in the Veterans Health Administration. | PSNet
    psnet.ahrq.gov/issue/healthcare-system-wide-implementation-opioid-safety-guideline-recommendations-case-urine-drug
    August 11, 2021 - This study across 141 facilities within the Department of Veterans Affairs (VA) health system demonstrated … Electronic medical record alert associated with reduced opioid and benzodiazepine coprescribing in high-risk Veteran … Affairs. … Affairs prevention initiative. … February 22, 2017 Inpatient suicide and suicide attempts in Veterans Affairs hospitals

84. Successful implementation of the Department of Veterans Affairs' National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study. | PSNet
    psnet.ahrq.gov/issue/successful-implementation-department-veterans-affairs-national-surgical-quality-improvement
    March 28, 2012 - Study Successful implementation of the Department of Veterans Affairs' National Surgical … Successful implementation of the Department of Veterans Affairs' National Surgical Quality Improvement … The Patient Safety in Surgery study documented remarkable improvements in postoperative outcomes at Veterans … Affairs hospitals following implementation of a quality improvement program.  … Successful implementation of the Department of Veterans Affairs' National Surgical Quality Improvement

85. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/844773/psn-pdf
    September 11, 2019 - How Veterans Affairs failed to stop a pathologist who misdiagnosed 3,000 cases. … https://psnet.ahrq.gov/issue/how-veterans-affairs-failed-stop-pathologist-who-misdiagnosed-3000-cases … This newspaper article discusses how a Veterans Affairs system pathologist with substance addiction … https://psnet.ahrq.gov/issue/how-veterans-affairs-failed-stop-pathologist-who-misdiagnosed-3000-cases

86. Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM) Shows Promise for Targeting Prevention Interventions to Reduce Mortality in Patients Who Are Prescribed Opioids | PSNet
    psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-mitigation-storm-shows
    October 30, 2024 - Department of Veterans Affairs (VA) study of nearly 124,000 veterans, those receiving the highest doses … Department of Veterans Affairs, Veterans Health Administration, Pharmacy Benefits Management Academic … Department of Veterans Affairs (VA), U.S. Department of Defense (DoD). … Office of Mental Health and Suicide Prevention, US Dept of Veterans Affairs; 2021. … Department of Veterans Affairs (VA), U.S. Department of Defense (DoD).

87. Critical Deficiencies at the Washington DC VA Medical Center. | PSNet
    psnet.ahrq.gov/issue/critical-deficiencies-washington-dc-va-medical-center
    December 16, 2020 - Washington, DC: Department of Veterans Affairs, Office of Inspector General. March 7, 2018. … Affairs, Office of Inspector General. … Systemic weaknesses in the Veterans Affairs health system have resulted in high-profile failures . … Washington, DC: Department of Veterans Affairs, Office of Inspector General. March 7, 2018. … Crisis Line Response to a Veteran Caller Who Died.

88. Incidence- versus prevalence-based measures of inappropriate prescribing in the Veterans Health Administration. | PSNet
    psnet.ahrq.gov/issue/incidence-versus-prevalence-based-measures-inappropriate-prescribing-veterans-health
    March 18, 2020 - This health system performance study ranked sites within the Veterans Affairs health system using … two measures of potentially inappropriate prescribing in older veterans. … Affairs: a multi-state qualitative study. … Affairs. … Electronic medical record alert associated with reduced opioid and benzodiazepine coprescribing in high-risk Veteran

89. The State of VA Health Care. | PSNet
    psnet.ahrq.gov/issue/state-va-health-care
    May 01, 2015 - Hearing Before the Committee on Veterans' Affairs United States Senate. 113th Cong (September 9, 2014 … ' Affairs United States Senate. 113th Cong (September 9, 2014). … In this hearing Veterans Affairs leadership provide an update on the current investigation into data … Hearing Before the Committee on Veterans' Affairs United States Senate. 113th Cong (September 9, 2014 … Affairs.

90. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/34802/psn-pdf
    January 01, 2016 - The Veterans Affairs root cause analysis system in action. … The Veterans Affairs Root Cause Analysis System in Action. … https://psnet.ahrq.gov/issue/veterans-affairs-root-cause-analysis-system-action This article focuses … Affairs (VA) facilities in the RCA process. … https://psnet.ahrq.gov/issue/veterans-affairs-root-cause-analysis-system-action https://psnet.ahrq.gov

91. Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida. | PSNet
    psnet.ahrq.gov/issue/patient-suicide-locked-mental-health-unit-west-palm-beach-va-medical-center-florida
    January 24, 2024 - Washington, DC: Department of Veterans Affairs, Office of Inspector General. August 22, 2019. … Affairs, Office of Inspector General. … This report describes an investigation into a patient suicide incident in the Veterans Affairs health … Washington, DC: Department of Veterans Affairs, Office of Inspector General. August 22, 2019. … Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans

92. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45972/psn-pdf
    April 05, 2017 - Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing … homes and non–Veterans Affairs nursing homes. … Comparing Catheter-Associated Urinary Tract Infection Prevention Programs Between Veterans Affairs Nursing … Homes and Non-Veterans Affairs Nursing Homes. … Researchers queried US Department of Veterans Affairs (VA) nursing homes and non-VA nursing homes participating

93. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/35462/psn-pdf
    February 18, 2011 - Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. … Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. … https://psnet.ahrq.gov/issue/effect-transformation-veterans-affairs-health-care-system-quality-care … Findings illustrated significant improvements over time for all indicators within the Veterans Affairs … https://psnet.ahrq.gov/issue/effect-transformation-veterans-affairs-health-care-system-quality-care https

94. Impact of the Opioid Safety Initiative on opioid-related prescribing in veterans. | PSNet
    psnet.ahrq.gov/issue/impact-opioid-safety-initiative-opioid-related-prescribing-veterans
    February 10, 2021 - Impact of the Opioid Safety Initiative on opioid-related prescribing in veterans. … This intervention at Veterans Affairs medical centers used an electronic dashboard to provide feedback … Electronic medical record alert associated with reduced opioid and benzodiazepine coprescribing in high-risk Veteran … Affairs. … Affairs prevention initiative.

95. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/60713/psn-pdf
    July 22, 2020 - Assessment of health information technology-related outpatient diagnostic delays in the US Veterans … Affairs health care system: a qualitative study of aggregated root cause analysis data. … Assessment of health information technology-related outpatient diagnostic delays in the US Veterans … Affairs health care system: a qualitative study of aggregated root cause analysis data. … Using root cause analysis data submitted to the Veterans Affairs (VA) National Center for Patient Safety

96. Lessons Learned? Building a Culture of Patient Safety Within the Veterans Health Administration. | PSNet
    psnet.ahrq.gov/issue/lessons-learned-building-culture-patient-safety-within-veterans-health-administration
    November 06, 2019 - Building a Culture of Patient Safety Within the Veterans Health Administration. … Building a Culture of Patient Safety Within the Veterans Health Administration. … US House of Representatives Committee on Veterans' Affairs Subcommittee on Health. … ' Affairs Subcommittee on Health.  117th Cong. 1 st Sess (2021). … US House of Representatives Committee on Veterans' Affairs Subcommittee on Health.

97. Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. | PSNet
    psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-fiscal-2021
    October 12, 2022 - Book/Report Evaluation of Quality, Safety and Value in Veterans Health Administration … Citation Text: Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities … Washington, DC: Veterans Affairs Office of Inspector General; 2022. Report No. 22-00818-03. … Affairs Office of Inspector General; 2022. … Washington, DC: Veterans Affairs Office of Inspector General; 2022. Report No. 22-00818-03.

98. Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses. | PSNet
    psnet.ahrq.gov/issue/disclosing-large-scale-adverse-events-us-veterans-health-administration-lessons-media
    August 18, 2021 - Study Disclosing large scale adverse events in the US Veterans Health Administration … Affairs health system, media reports did not convey specific aspects of error disclosure , such as … Affairs leadership, policymaker, research and stakeholder partnership. … Electronic medical record alert associated with reduced opioid and benzodiazepine coprescribing in high-risk Veteran … Affairs prevention initiative.

99. Urinary Incontinence Clinician Pocket Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/evidencenow/projects/urinary/resources/clinician-pocket-guide.html
    June 01, 2024 - outlines lifestyle modifications, diagnosis codes, and treatment options for urinary incontinence for Veterans … Institution of origin Birmingham Veterans Affairs (VA) Health Care System & Atlanta Veterans Affairs

100. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45851/psn-pdf
     February 22, 2017 - decreased methicillin-resistant Staphylococcus aureus health care–associated infections associated with a Veterans … Affairs prevention initiative. … Affairs prevention initiative. … Researchers attribute these results to implementation of the Veterans Affairs MRSA Prevention Initiative … psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus https://psnet.ahrq.gov/issue/veterans-affairs-initiative-prevent-methicillin-resistant-staphylococcus-aureus-infections