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psnet.ahrq.gov/node/50842/psn-pdf
January 29, 2020 - Patient Identification Errors: A Systems Challenge
January 29, 2020
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
The Cases
The following four events involving five patients all involved…
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psnet.ahrq.gov/node/73999/psn-pdf
October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in
the Operating Room
October 27, 2021
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
…
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psnet.ahrq.gov/node/49466/psn-pdf
October 14, 2004 - Hard to Swallow
October 1, 2004
Driver J. Hard to Swallow. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/hard-swallow
The Case
An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic
attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
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meps.ahrq.gov/data_files/publications/st514/stat514.shtml
August 01, 2018 - STATISTICAL BRIEF #514: Reported Diagnosis and Prescription Utilization Related to Attention Deficit Hyperactivity Disorder in Children Ages 5–17, 2008–2015
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An official website of the Departm…
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www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual/procedure-manual-section-2-topic-selection-prioritization-and-updating
June 22, 2025 - Procedure Manual Section 2. Topic Selection, Prioritization, and Updating
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The Task Force has a large library of current topics and frequently receives nominations for new top…
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psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
October 23, 2013 - Building a Safety Program Using Principles of Resilience Engineering
Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS | June 1, 2019
View more articles from the same authors.
Citation Text:
Hegde S, Fairbanks RJ, Bisantz A. Building a Safety…
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/osteoporosis-screening
November 18, 2021 - Share to Facebook
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Final Research Plan
Osteoporosis to Prevent Fractures: Screening
November 18, 2021
Recommendations made by the USPSTF are independent of the U.S. government. They should not b…
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psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
September 01, 2005 - Benefits vs. Risks of Intraosseous Vascular Access
Citation Text:
Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/49569/psn-pdf
September 01, 2008 - Where's the Feeding Tube?
September 1, 2008
Metheny NA, Meert KL. Where's the Feeding Tube? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wheres-feeding-tube
The Case
A 13-year-old boy was involved in a motor vehicle collision and experienced a traumatic brain injury.
Because of the injuries, he was unabl…
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psnet.ahrq.gov/node/33816/psn-pdf
October 01, 2016 - In Conversation With… Richard Platt, MD, MSc
October 1, 2016
In Conversation With… Richard Platt, MD, MSc. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
Editor's note: Dr. Platt is Professor and Chair of the Harvard Medical School Department of Population
Medicine. He…
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psnet.ahrq.gov/node/73515/psn-pdf
August 01, 2022 - Missouri Quality Initiative (MOQI) Reduces
Hospitalizations Among Nursing Home Residents
July 28, 2021
https://psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-
home-residents
Summary
The MOQI seeks to reduce avoidable hospitalization among nursing home residents b…
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/pbrn-webinar-2-highlighting-promoting.pdf
September 01, 2024 - AHRQ PBRN Webinar: Highlighting and Promoting the Value of PBRNs
Highlighting and Promoting the
Value of Practice - Based Research
Networks (PBRNs)
July 11, 2024
4 p.m. – 5 p.m. ET
Housekeeping and Logistics
• Closed Captioning is
available through Zoom.
• If you have questions,
submit them in the Q&A t…
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/operational-adjustments-event-summary.pdf
July 02, 2020 - 1
Learning Community Affinity Group
Summary-at-a-Glance:
Operational Adjustments while Resuming In-Person Cardiac
Rehabilitation Programs
July 2, 2020
Event Purpose and Overview
• Purpose: To share and acquire strategies for how to adjust operations while resuming in-person
cardiac rehabilitation p…
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psnet.ahrq.gov/node/49715/psn-pdf
August 21, 2014 - Liver Biopsy: Proceed With Caution
August 21, 2014
Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
The Case
A 42-year-old woman with a history of multiple malignancies, including osteosarcoma and recurrent breast
cancer, presented t…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/fecal-incontinence_consumer.pdf
July 01, 2016 - Treatments for Fecal Incontinence: A Review of the Research for Adults
Treatments for Fecal
Incontinence
A Review of the Research for Adults
e
Archived: This report is greater than 3 years
old. Findings may be used for research
purposes, but should not be considered
current
…
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - Patient Safety 101
Citation Text:
Patient Safety 101. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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D…
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digital.ahrq.gov/ahrq-funded-projects/evaluating-impact-acpoecds-system-outcomes
January 01, 2023 - Evaluating the Impact of an ACPOE/CDS System on Outcomes
Project Final Report ( PDF , 806.9 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHR…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hp/Child_Med_Eng_HP50_2155a.pdf
September 01, 2015 - CAHPS Health Plan Survey Child Medicaid Survey 5.0
CAHPS® Health Plan Surveys
Version: Child Medicaid Survey 5.0
Language: English
Notes
• Release of 5.0 version: The CAHPS Health Plan Surveys were updated in the Spring of
2012. The updates are limited to minor changes to the wording of several items and a …
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psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and-disclosure
February 26, 2025 - “Behavioral Health Vital Signs” Initiative Increases Patient Education and Disclosure about Interpersonal Violence (IPV)
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June 30, 2021
Innovat…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/022-ss-mrsa-surveillance.pptx
April 01, 2025 - PowerPoint Presentation
AHRQ Safety Program for MRSA Prevention: Targeting SSI
MRSA Surveillance
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
AHRQ Pub. No. 25-0029
April 2025
AHRQ Safety Program for MRSA Prevention | Surgical Services
MRSA Surveillance
1
Educational …