-
psnet.ahrq.gov/node/49749/psn-pdf
December 01, 2015 - Hyperglycemia and Switching to Subcutaneous Insulin
December 1, 2015
Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
The Case
A 47-year-old man with type 2 diabetes was admitted to the hospita…
-
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module5-presenters-notes.pdf
January 10, 2022 - TeamSTEPPS® Diagnosis Improvement: Module 5 Situation Monitoring To Improve Diagnosis - Facilitator’s Notes
Slide 1
TeamSTEPPS® for Diagnosis
Improvement
…
-
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module5-situation-monitoring.pptx
January 10, 2022 - Module 5: Situation Monitoring
Module 5
Situation Monitoring To Improve Diagnosis
TeamSTEPPS® for Diagnosis Improvement
Welcome to the TeamSTEPPS for Diagnosis Improvement Course. This presentation will cover Module 5, Situation Monitoring To Improve Diagnosis, that you will review as the facilitator.
Individual…
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-rr-webcast-011124-elliott.pdf
September 30, 2021 - CAHPS Program: Improving Response Rates and Representativeness - The CAHPS Hospital, CAHPS Hospice, and MA/PDP CAHPS Surveys: Lessons Learned from Recent Mode Experiments
The CAHPS Hospital, CAHPS Hospice,
and MA/PDP CAHPS Surveys:
Lessons Learned from Recent Mode Experiments
Marc Elliott
Senior Principal Researc…
-
psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one
April 24, 2018 - Written Signout: It Only Works If You Use The Right One
Citation Text:
Lewis K, Rosenbluth G. Written Signout: It Only Works If You Use The Right One. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
Format:
…
-
www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/practice-survey-ny.pdf
June 02, 2025 - Practice Survey
P a g e | 1
Practice Survey-demographics/E…
-
psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
March 29, 2023 - Walking Out of a Hospital After Attempted Suicide
Citation Text:
Bourgeois JA, Xiong G. Walking Out of a Hospital After Attempted Suicide. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Citation
Format:
Googl…
-
psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
January 24, 2018 - Primary Workaround, Secondary Complication
Citation Text:
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
Format:
Google Scholar B…
-
psnet.ahrq.gov/web-mm/hold-order
December 19, 2018 - Hold That Order
Citation Text:
Grissinger M. Hold That Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/ptfamcare-slides.pptx
January 01, 2017 - Presentation: Program Overview
Patient and Family Involvement in Care of Mechanically Ventilated Patients
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-37-EF
January 2017
Patient/Family Involvement ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
1
Learning Obje…
-
psnet.ahrq.gov/node/49562/psn-pdf
May 01, 2008 - The Inside of a Time Out
May 1, 2008
Feldman DL. The Inside of a Time Out. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/inside-time-out
The Case
A 65-year-old man was scheduled for an elective endovascular repair of an abdominal aortic aneurysm.
The patient had an allergy to "IV contrast dye" that was no…
-
psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
February 01, 2014 - Wrong-Time Error With High-Alert Medication
Citation Text:
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTeX…
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/effect-dietary-digestible-disposition-comments_0.pdf
March 03, 2025 - Disposition of Comments_Systematic Review: The Relationship of Digestible Carbohydrate Intake With Cardiovascular Disease, Type 2 Diabetes, Obesity, and Body Composition
Systematic Review Disposition of Comments Report
Title: Association of Digestible Carbohydrate Intake With Cardiovascular Disease, Type 2
Diabete…
-
psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - The Soil, Not the Seed: The Real Problem with Root
Cause Analysis
July 1, 2008
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
Perspective
Throughout most of his life, …
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
December 01, 2007 - products/safeplaceed/
Successful Prevention
Overarching goal is safe patient care
Must link adequate
-
www.uspreventiveservicestaskforce.org/uspstf/recommendation/vitamin-d-calcium-or-combined-supplementation-for-the-primary-prevention-of-fractures-in-adults-preventive-medication
April 17, 2018 - The USPSTF found adequate evidence that daily supplementation with 400 IU or less of vitamin D combined … Harms of Preventive Medication
The USPSTF found adequate evidence that supplementation with vitamin … The USPSTF found adequate evidence that vitamin D supplementation does not prevent falls. … the National Academy of Medicine) 37 and the World Health Organization 38 recommend standards for adequate
-
psnet.ahrq.gov/node/49420/psn-pdf
October 01, 2003 - not receive important information directly from the referring provider, the ED failed to obtain an
adequate
-
psnet.ahrq.gov/node/50606/psn-pdf
October 30, 2019 - One doctor. 25 deaths. How could it have happened?
October 30, 2019
Healy J, Farr I, Feiger L, Duffy C. New York Times. October 11, 2019.
https://psnet.ahrq.gov/issue/one-doctor-25-deaths-how-could-it-have-happened
Systemic failures persistently undermine processes meant to keep patients safe. This news story discu…
-
psnet.ahrq.gov/node/37246/psn-pdf
December 16, 2011 - Nurses' experiences of drug administration errors.
December 16, 2011
Schelbred A-B, Nord R. Nurses' experiences of drug administration errors. J Adv Nurs. 2007;60(3):317-24.
https://psnet.ahrq.gov/issue/nurses-experiences-drug-administration-errors
This qualitative study describes the experiences of nurses who comm…
-
psnet.ahrq.gov/node/35671/psn-pdf
June 25, 2010 - Nursing Homes: Despite Increased Oversight, Challenges
Remain in Ensuring High-Quality Care and Resident
Safety.
June 25, 2010
Washington DC; Government Accountability Office; 2005. Report no. GAO-06-117.
https://psnet.ahrq.gov/issue/nursing-homes-despite-increased-oversight-challenges-remain-ensuring-high-
quali…