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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/49819/psn-pdf
February 01, 2018 - Signout Fallout
February 1, 2018
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/signout-fallout
Case Objectives
Understand the role of communication failures in medical errors and preventable adverse events.
Review the evidence in support of handoff improvement pr…
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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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integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/plan-integrate-mat-for-oud/understanding-components-of-mat
February 01, 2025 - An official website of the Department of Health & Human Services
Search All AHRQ Sites
Careers
Contact Us
Español
FAQs
Email Updates
The Academy
Integrating Behavioral Health & Primary Care
Expand Navi…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/3-sorra-sops-hospital-survey-2-0-webcast.pdf
July 20, 2020 - AHRQ Webcast Introducing the New SOPS Hospital Survey 2.0 - Sorra
AHRQ Surveys on Patient Safety Culture™
Hospital Survey Version 2.0
Joann Sorra, PhD
Project Director, AHRQ Surveys on Patient Safety Culture User Network, Westat
12
HSOPS 2.0 Development Team
• Westat Research Team:
Theresa Famolaro, MPS, MS, …
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/reports-and-case-studies/ExecSummcaseplancustsvce-RAND7607.pdf
July 01, 2007 - 1
IMPROVING PERFORMANCE FOR
HEALTH PLAN CUSTOMER SERVICE
A Case Study of a Successful CAHPS
Quality Improvement Intervention
Excerpt: The Case Study in Brief
For a copy of the full report, go to http://www.rand.org/pubs/working_papers/WR517/
July 2007
Denise D. Quigley,…
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www.ahrq.gov/sites/default/files/publications2/files/dx-issue-brief-20-brazil-health-system.pdf
August 01, 2024 - Learning from AHRQ's Diagnostic Safety Culture Survey at a Tertiary Care Health System in Brazil: A Case Study
PATIENT
SAFETY
e
Issue Brief 20
Learning from AHRQs’ Diagnostic Safety
Culture Survey at a Tertiary Care Health
System in Brazil: A Case Study
This page intentionally left blank.
e
Issue Brief 2…
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www.ahrq.gov/ncepcr/reports/2025-annual-report/patient-safety.html
August 01, 2025 - AHRQ’s Investments in Primary Care Research for 2023 and 2024
Patient Safety
Previous Page Next Page
Table of Contents
AHRQ’s Investments in Primary Care Research for 2023 and 2024
Acknowledgements and Authors
Message from the Director of AHRQ’s National Center for Excellence in Primary Care R…
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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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effectivehealthcare.ahrq.gov/sites/default/files/pdf/insomnia_clinician.pdf
August 01, 2017 - Management of Insomnia Disorder in Adults: Current State of the Evidence
Management of Insomnia Disorder in Adults:
Current State of the Evidence
Focus of This Summary
This is a summary of a systematic review that evaluated current evidence regarding the effectiveness, comparative effectiveness,
and adverse effec…
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psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
February 21, 2024 - The Safety Challenges of Supervision and Night Coverage in Academic Residency
Citation Text:
Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019…
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psnet.ahrq.gov/node/73456/psn-pdf
June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult
Intubation and Severe Hypoxemia
June 30, 2021
Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…
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www.ahrq.gov/sites/default/files/2025-07/weinger3-report.pdf
January 01, 2025 - Final Progress Report: IMPACTS: Improving Medical Performance during Acute Crises Through Simulation
IMPACTS: Improving Medical Performance during Acute Crises Through Simulation
Principal Investigator: Matthew B. Weinger, MD, MS
IMPACTS Team: Anders, Shilo; Andreae, Michael; Banerjee, Arna; Boulet, Jack; Burden, A…
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs024739-nahm-final-report-2019.pdf
January 01, 2019 - A Theory-Based Patient Portal eLearning Program for Older Adults with Chronic Illnesses - Final Report
Nahm 1
Final Report for R21HS024739
Title of Project: A Theory-Based Patient Portal eLearning Program for Older Adults with Chronic Illnesses
Principal Investigator and Team Members.
Investigators…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-resource-list.pdf
April 01, 2023 - three-part toolkit to help outpatient care settings improve
safety in three areas: working as a team, assessing … resources by providing chief executive officers and other healthcare leaders
with a useful tool for assessing
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/main-apps-surv-report-3-acute-pain.pdf
June 01, 2022 - assessed the quality of individual controlled trials using the approach recommended
in the chapter Assessing … Assessing the risk of bias of individual
studies in systematic reviews of health care
interventions … diagnostic accuracy
h. cohort studies and before-after studies
assessing effects on prescribing rates … Assessing outcome in postoperative pain
trials: are we missing the point? … Assessing the risk of bias of individual
studies in systematic reviews of health care
interventions
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psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
December 01, 2012 - be prevented if things were handled perfectly, the argument would be that we need a standard way of assessing
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/manage-resident-UTI-facilitator-guide.docx
June 01, 2021 - There are pocket cards available describing indications to send a urine culture, decision trees for assessing
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight05.html
November 01, 2013 - Assessing the utility of other innovative approaches to enhance quality.
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
January 31, 2024 - Although clinicians and researchers endorse the importance of patient-centeredness in assessing misdiagnosis