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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
…
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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…
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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…
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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 …
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/teamwork-ptsafety-norms-slides.pdf
June 30, 2025 - Improving Safety Using Teamwork and Patient Safety Norms
Creating and Maintaining a Culture of Safety Series
(Session 2)
Improving Safety Using Teamwork and Patient Safety Norms
NATIONAL WEBINAR SERIES
March 18, 2025
Housekeeping Instructions
• This webinar will be recorded and available for viewing on the NAA…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/diagnostic-safety-resources.pdf
May 01, 2023 - Diagnostic Safety Resource List
Improving Diagnostic Safety in Medical Offices:
A Resource List for Users of the AHRQ Diagnostic
Safety Supplemental Item Set
I. Purpose
This document provides a list of references to websites and other publicly available resources that
medical offices can use to improve the ex…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/patient-safety-technology-resources.pdf
May 01, 2023 - Improving Health Information Technology (IT) Patient Safety: A Resource List for Users of the AHRQ Health Information Technology Supplemental Item Set
SOPS Health IT Patient Safety Supplemental Item Set Resource List 1
Improving Health Information Technology (IT) Patient
Safety: A Resource List for Users of the A…
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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…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
June 02, 2025 - SAY:
The Patient and Family Engagement module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit focuses on an important topic: Making sure patients and their family members understand what is happening during the patient’s hospital stay, are active participants in the patient’s care, and are prepared for…
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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…
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www.ahrq.gov/patient-safety/settings/hospital/vtguide/appb2.html
January 01, 2020 - Preventing Hospital-Associated Venous Thromboembolism
Appendix B: Risk Assessment Models, Protocols, and Order Sets (continued)
Previous Page Next Page
Table of Contents
Preventing Hospital-Associated Venous Thromboembolism
Preface
Executive Summary
Chapter 1. The Framework for Improvement
C…
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psnet.ahrq.gov/node/49506/psn-pdf
March 01, 2006 - The Wet Read
March 1, 2006
Arenson RL. The Wet Read. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/wet-read
Case Objectives
Appreciate the limitations of radiology resident emergency coverage.
Understand the rate of discrepancy between radiology resident preliminary reads and attending
radiologists' fina…
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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…
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu1.html
October 01, 2014 - Preventing Pressure Ulcers in Hospitals
1. Are we ready for this change?
Previous Page Next Page
Table of Contents
Preventing Pressure Ulcers in Hospitals
Overview
Key Subject Area Index
1. Are we ready for this change?
2. How will we manage change?
3. What are the best practices in pressu…
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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…
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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…
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www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/summary.html
August 01, 2022 - Demonstration Grants Final Evaluation Report
Executive Summary
Previous Page Next Page
Table of Contents
Demonstration Grants Final Evaluation Report
Executive Summary
Detailed Findings
Evaluation Issues
Contributions to Patient Safety and Medical Liability
Lessons Learned From Implement…
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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…
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight04.html
October 01, 2013 - How the CHIPRA quality demonstration elevated children on State health policy agendas
Evaluation Highlight No. 4
Authors: Nicole Cafarella Lallemand, Elizabeth Richardson, Kelly Devers, and Lisa Simpson
Contents
Key Messages
Background
Findings
Conclusions
Implications
Learn More
Endnotes
…
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www.ahrq.gov/prevention/resources/depression/depsum2.html
April 01, 2013 - Screening for Depression in Adults (continued)
The summaries of the evidence briefly present evidence of effectiveness for preventive health services used in primary care clinical settings, including screening tests, counseling, and chemoprevention. They summarize the more detailed Systematic Evidence Reviews, …