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  1. A Double “Never Event”: Wrong Patient and Wrong Side. | PSNet

    psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
    August 20, 2018 - A Double “Never Event”: Wrong Patient and Wrong Side. Citation Text: Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49579/psn-pdf
    March 21, 2009 - All in the History March 21, 2009 Fee C. All in the History. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/all-history Case Objectives Describe the Emergency Medical Treatment and Active Labor Act (EMTALA) and understand that it does not apply to transfers to emergency departments from non-acute care faci…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73642/psn-pdf
    August 25, 2021 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected August 25, 2021 Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect- unexpected …

  4. Errors in Sepsis Management | PSNet

    psnet.ahrq.gov/web-mm/errors-sepsis-management
    November 03, 2015 - SPOTLIGHT CASE Errors in Sepsis Management Citation Text: Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49825/psn-pdf
    April 01, 2018 - When Patients and Providers Speak Different Languages April 1, 2018 Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages Case Objectives Understand the legal and regulatory obligations to prov…

  6. Slippery Slide Into Life | PSNet

    psnet.ahrq.gov/web-mm/slippery-slide-life
    January 21, 2017 - Slippery Slide Into Life Citation Text: Halamek LP. Slippery Slide Into Life. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …

  7. Nursingnotes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/nursing/nursingnotes.docx
    June 02, 2025 - SAY: The Role of the Nurse Manager module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit addresses the role of nursing leaders for your quality improvement initiative. This module explains the responsibilities of the nurse manager, leadership and management roles of the nurse manager, key business and…

  8. Final progress Report: Spaced Education to Optimize Prostate Cancer Screening (pdf file)

    www.ahrq.gov/sites/default/files/2024-03/kerfoot-conlin-report.pdf
    January 01, 2024 - Final progress Report: Spaced Education to Optimize Prostate Cancer Screening Title Page Title of Project: Spaced Education to Optimize Prostate Cancer Screening Principal Investigator and Team Members: B. Price Kerfoot, MD, EdM – Principal Investigator Paul R. Conlin, MD – Primary Mentor Organization: Harvard Uni…

  9. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
    January 01, 2022 - Spotlight Spotlight Delayed Diagnosis of Mesenteric Ischemia Source and Credits • This presentation is based on the August 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Anamaria Robles, MD, and Garth Utter, MD, MSc o AHRQ WebM&M…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49454/psn-pdf
    July 01, 2004 - Novel Drug Misuse July 1, 2004 Angus DC, Milbrandt EB. Novel Drug Misuse. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/novel-drug-misuse Case Objectives Define the inclusion and exclusion criteria for patients in PROWESS. Understand why the FDA included APACHE score as an indication criterion for drotrec…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49585/psn-pdf
    May 01, 2009 - Delirium or Dementia? May 1, 2009 Rudolph JL. Delirium or Dementia? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/delirium-or-dementia Case Objectives State the key diagnostic differences between delirium and dementia. Describe the Confusion Assessment Method for workup of suspected delirium. Explain the…

  12. U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument | PSNet

    psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
    February 26, 2025 - U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL January …

  13. PowerPoint Presentation

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
    August 21, 2015 - PowerPoint Presentation Communication and Optimal Resolution (CANDOR) Toolkit Module 5: Response and Disclosure Communication In Module 5 of the CANDOR Toolkit, we will discuss the Response and Disclosure component of the CANDOR process. 1 Objectives Define the Response and Disclosure component of the CANDOR Proc…

  14. PowerPoint Presentation

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-erepguide_slides.pptx
    November 01, 2016 - PowerPoint Presentation AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing Facilitator Training Introduction to Pressure Ulcer Healing Reports 1 Electronic Reports Existing Pressure Ulcers Report Pressure Ulcers at Risk for Delayed Healing Weekly Wound Rounds Report Weekly Pressure Ulcer Treat…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865540/psn-pdf
    April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration April 11, 2024 Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration The Case An 82-year-old woman presented to the Emergency Department (ED) for …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863308/psn-pdf
    February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy February 28, 2024 Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy The Case A…

  17. Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart | PSNet

    psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
    October 30, 2024 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL June 12, 2020 …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865411/psn-pdf
    March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy March 27, 2024 Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…

  19. Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx Spotlight Respiratory Distress after Neck Surgery: Two Cases of Post-Operative Cervical Hematoma Source and Credits • This presentation is based on the January 2023 AHRQ WebM&M Spotlight Case o See the full article at https://…

  20. Final Progress Report: Safety Advancement in the Emergency Department (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/hall2-report.pdf
    January 01, 2024 - Final Progress Report: Safety Advancement in the Emergency Department FINAL PROGRESS REPORT PROJECT TITLE: SAFETY ADVANCEMENT IN THE EMERGENCY DEPARTMENT* PRINCIPAL INVESTIGATOR: KENDALL K. HALL, MD, MS (AHRQ, formerly of UNIV of MARYLAND) KEY PERSONNEL: YAN XIAO, PhD (BAYLOR, formerly of UNIV of MARYLAND) ANTHO…
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