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  1. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/slides.html
    November 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training Slide Presentation Text version of slide presentation. Slide 1: Introduction to Falls Reports AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training Introduction to Falls Reports Sl…
  2. effectivehealthcare.ahrq.gov/sites/default/files/pdf/white-paper-lumbar-spondylolisthesis.pdf
    March 01, 2021 - White Paper: Standardized Library of Lumbar Spondylolisthesis Outcome Measures Research White Paper Standardized Library of Lumbar Spondylolisthesis Outcome Measures Research White Paper Standardized Library of Lumbar Spondylolisthesis Outcome Measures Prepared for: …
  3. psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
    May 01, 2011 - SPOTLIGHT CASE The Wrong Shot: Error Disclosure Citation Text: Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Sch…
  4. psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
    January 29, 2020 - Delayed Recognition of a Positive Blood Culture Citation Text: Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibT…
  5. psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
    November 01, 2003 - CVC Placement: Speak Now or Do Not Use the Line Citation Text: Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49570/psn-pdf
    October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure? October 1, 2008 Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure Case Objectives Understand the complementary abilities of an electronic health record a…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854897/psn-pdf
    October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose October 31, 2023 Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/weight-and-…
  8. psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
    October 19, 2022 - SPOTLIGHT CASE Resuscitation Errors: A Shocking Problem Citation Text: Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: …
  9. www.ahrq.gov/sites/default/files/2024-11/ballard-report.pdf
    January 01, 2024 - Final Progress Report: Using Performance Measurement To Improve the Quality and Safety of Healthcare Element 1. Title Page: Using Performance Measurement to Improve the Quality and Safety of Healthcare Report on The International Society for Quality in Health Care (ISQua) 6th International Summit on Indic…
  10. psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
    November 15, 2023 - Complications of Vascular Access Procedures in Patients with Kidney Disease Citation Text: Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49540/psn-pdf
    August 21, 2007 - Resuscitation Errors: A Shocking Problem August 21, 2007 Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem Case Objectives Appreciate that delays in defibrillation can have significant negative effects on sur…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49669/psn-pdf
    November 01, 2012 - Transfusion Overload November 1, 2012 Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfusion-overload Case Objectives Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit below 30% are not supported by the evidence.…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49639/psn-pdf
    November 01, 2011 - Near Miss with Bedside Medications November 1, 2011 Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications Case Objectives Understanding the definition of near miss—also known as close call. Appreciate the importance of close calls in reducin…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49865/psn-pdf
    June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy June 1, 2019 Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy The Case A 75-year-old man with a past medical history of hemorrhagic stroke, coron…
  15. psnet.ahrq.gov/web-mm/transfer-or-not-transfer
    November 23, 2016 - SPOTLIGHT CASE To Transfer or Not to Transfer Citation Text: Pines JM. To Transfer or Not to Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853773/psn-pdf
    September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side. September 27, 2023 Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side The Case A first-year orthopedic surgery resident was consulted…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72811/psn-pdf
    September 01, 2022 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors Originally published on March 3, 2021 Last updated on March 16, 2021 https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during- initial-treatment Summar…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49705/psn-pdf
    January 01, 2020 - A "Reflexive" Diagnosis in Primary Care April 1, 2014 Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care Case Objectives Appreciate that primary care doctors may be caring for an increasing number of patients wi…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49516/psn-pdf
    August 01, 2006 - Physical Diagnosis: A Lost Art? August 1, 2006 Thompson GR, Verghese A. Physical Diagnosis: A Lost Art? PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art Case Objectives Appreciate the decline in proficiency and reliance on physical examination skills among health care providers. …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49712/psn-pdf
    June 01, 2014 - May I Have Another?—Medication Error June 1, 2014 Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error The Case A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a pharmacology-tra…