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psnet.ahrq.gov/node/865376/psn-pdf
March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a
Patient Admitted for Leg Fractures
March 27, 2024
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…
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psnet.ahrq.gov/node/49676/psn-pdf
February 01, 2013 - Death by PCA
February 1, 2013
Hicks RW. Death by PCA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/death-pca
The Case
A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an
uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
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psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care
September 30, 2011 - Safeguarding Diagnostic Testing at the Point of Care
Citation Text:
Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
…
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psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx
Spotlight
Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the ful…
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psnet.ahrq.gov/node/49699/psn-pdf
February 01, 2014 - Multifactorial Medication Mishap
February 1, 2014
Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
Case Objectives
Understand the system-based causes of medication errors.
Describe a model for a systems approach to error analysis.
Id…
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - Open wider: Failure to use an interpreter results in
fractured teeth and hypoxia during a simple elective
operation.
December 14, 2022
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia
during a simple elective operation. PSNet [internet]. 2022.
https://psnet.ah…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0138-fullreport.pdf
April 01, 2018 - Validity
Face validity is the degree to which the measure construct characterizes the concept being
assessed … administrative claims data; therefore, the validity of the coded data
reported in Medicaid claims was assessed … This measure has not been assessed for comprehension.
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www.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
January 01, 2024 - Samples Use Card Study
This study assessed the frequency, motivation for, and safety of manufacturer-provided … A card study
assessed provider motivation and sample dispensing. … A simultaneous card study assessed patient
knowledge of their sample(s).
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www.ahrq.gov/sites/default/files/2025-03/chaudhry-report.pdf
January 01, 2025 - Staff Experience survey: This survey assessed MICU, ED, and GM clinicians’ experiences with sending and … Our
evaluation plan assessed patient outcomes, intervention fidelity, and participant experience. … • YNHH Patient Discharges to SNFs survey: This survey assessed SNF clinicians’ experiences with hospital
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digital.ahrq.gov/sites/default/files/docs/citation/r18hs017191-pohl-final-report-2011.pdf
January 01, 2011 - with Influenza Vaccine
• % with 2 HbA1c values in last yr (3+ mths apart)
• % with HbA1c value
• % assessed … This
survey assessed computer literacy and attitudes/expectations regarding the effect of ‘computers … inhibitors or ARBs; on Statins; blood pressure measured; taking Aspirin or Antithrombotic; smoking
status assessed
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs025429-aguilera-final-report-2022.pdf
January 01, 2022 - After
6 months, we again assessed the most recent HbA1c (pulling from patients’ EHR), ensuring that … such
as (1) times that the app was opened (2) time spent reading the messages (3) usability data, assessed … algorithm (an area of machine learning) based on previous work.28 On a daily
basis, this algorithm assessed
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/k-btyK4W2-v9KnemTK8WDx
September 14, 2021 - Two investigators independently assessed study quality. … Two independent investigators assessed the quality of
each study as good, fair, or poor using predefined … Data Synthesis
Two independent reviewers assessed the internal validity
(quality) of the body of evidence
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/juvenile-arthritis-dmards_disposition-comments.pdf
September 01, 2011 - comparison
have a high likelihood of adequate protection
against bias (i.e., good internal validity),
assessed … No other
studies that assessed uveitis met the
inclusion criteria. … Will refer to standard joint count, with 71
joints assessed throughout.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/exercises2.html
December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention
Facilitator Training—Additional Exercises (continued)
Risk Change Report Information Exercises
Objective: Facilitators will understand the process to prioritize residents on the Risk Change Report for use in On‐Time process improvem…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/6.html
December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention
Functional Specifications
3. Specifications for Each Pressure Ulcer Prevention Report (continued)
3.6. Risk Change Report (formerly Priority Report)
3.6.1. Report Description
The On-Time Risk Change Report (formerly Priority Repo…
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www.ahrq.gov/news/newsletters/e-newsletter/924.html
August 01, 2024 - Intervention Leads to Increase in Lung Cancer Screenings
Issue Number
924
AHRQ News Now is a weekly newsletter that highlights agency research and program activities.
August 6, 2024
AHRQ Stats Access more data on this topic in AHRQ's 2023 Chartbook on Patient Safety (PDF, 4 MB), plus additional AHRQ …
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www.ahrq.gov/faqs/index.html?page=5
June 12, 2025 - Frequently Asked Questions
Check to find the answers to your questions about the Agency for Healthcare Research and Quality (AHRQ)
programs and activities. You can search by category or key words. You can also send us your questions or website
feedback here. We will respond to your requests based on the bes…
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www.ahrq.gov/hai/cusp/cauti-interim/cauti-interim5.html
July 01, 2013 - Eliminating CAUTI: Interim Data Report
Conclusions
Previous Page
Table of Contents
Eliminating CAUTI: Interim Data Report
Executive Summary
Introduction and Objectives
Methods
Results
Outcome and Process Measures
Culture Measures
Conclusions
The national project team …
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/04-SOPS_101_Webcast-FAMOLARO.pdf
January 01, 2020 - Understanding SOPS Surveys: A Primer for New Users (Webcast) - Famolaro
The SOPS Databases
Theresa Famolaro, MPS, MS, MBA
Senior Study Director
User Network for the AHRQ Surveys on Patient Safety Culture (SOPS)
Westat
23
SOPS Databases
Hospital
630
Hospitals
Nursing
Home
191
Nursing Homes
Medical
Office…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/improve/discussion-guide.docx
March 01, 2017 - BLADDER SCAN – POLICY #2202 12/11/06
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
AHRQ Safety Program for Reducing CAUTI in Hospitals
Appendix B.
Guide to Administering the AHRQ Nursing Home Survey on Patient Safety Culture and Reviewing Results
The purpose of this guide is to provide you with information on h…