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psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - Diagnostic Overshadowing Dangers
Citation Text:
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/departure-central-line-ritual
October 13, 2018 - Departure From Central Line Ritual
Citation Text:
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndN…
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www.ahrq.gov/sites/default/files/2024-04/naughton-report.pdf
January 01, 2024 - Final Progress Report: Pneumonia Mortality Risk Index to Support Discussions of Care Options with Elders
TITLE PAGE
FINAL Progress Report for 1R03HS023656-01A1
FINAL REPORT Period: 08/01/2015 – 07-31/2017
Project Title: Pneumonia Mortality Risk Index to Support Discussions of Care Options with Elders …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/sustainability/communication-strategies-guide.docx
January 01, 2017 - Facilitator Guide: Communication Strategies for Sustainability
Slide Title and Commentary
Slide Number and Slide
Title Slide
Communication Strategies for Sustainability
SAY:
In this slide set, you’ll learn about communication strategies to sustain your safety program work.
Slide 1
Learning Objectives
SAY:
Af…
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psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - Spotlight
Spotlight
False Assumptions Result in a Missed
Pneumothorax after Bronchoscopy with
Transbronchial Biopsy
Source and Credits
• This presentation is based on the September 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:…
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psnet.ahrq.gov/node/49451/psn-pdf
June 01, 2004 - The Result Stopped Here
June 1, 2004
Astion ML. The Result Stopped Here. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/result-stopped-here
The Case
A 91-year-old female was transferred to a hospital-based skilled nursing unit from the acute care hospital
for continued wound care and intravenous (IV) antib…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_facnotes.docx
December 01, 2017 - Facilitator Guide: Science of Safety Training & Identifying Defects
Science of Improving Safety and Identifying Defects – Facilitator Notes
Slide Title and Commentary
Slide Number and Slide
Title Slide
The Science of Improving Patient Safety and Identifying Defects
SAY:
The topic of this module is the science of …
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/program-part1-facilitator-guide.pdf
November 01, 2019 - Antibiotic Stewardship Program Development: Part 1
AHRQ Safety Program for Improving
Antibiotic Use
1
AHRQ Pub. No. 17(20)-0028-EF
November 2019
Antibiotic Stewardship Program
Development: Part 1
Acute Care
Slide Title and Commentary Slide Number and Slide
Antibiotic Stewardship Pr…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
May 01, 2017 - PowerPoint Presentation
Spotlight
Diagnostic Delay in the Emergency Department
1
Source and Credits
This presentation is based on the May 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Kyle Marshall, MD, Geisinger Medical Center, Danv…
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psnet.ahrq.gov/node/49621/psn-pdf
March 01, 2011 - Volume Too Low: In and Out
March 1, 2011
Miller MR. Volume Too Low: In and Out . PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/volume-too-low-and-out
Case Objectives
Appreciate that because of multiple factors, children are at high risk for medical errors.
Describe the importance of weight-based dosing of…
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psnet.ahrq.gov/web-mm/other-hand
December 12, 2012 - On the Other Hand
Citation Text:
Henneman EA. On the Other Hand. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
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psnet.ahrq.gov/web-mm/case-patient-flow-management
February 23, 2019 - The Case for Patient Flow Management
Citation Text:
Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Google Scholar BibTeX EndNote X…
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs024071-lindquist-final-report-2018.pdf
January 01, 2018 - Improving Outpatient Safety of Older Adults through Electronic Patient Portals - Final Report
1
AHRQ Grant Final Progress Report
Title of Project: Improving Outpatient Safety of Older Adults through Electronic Patient Portals
Principal Investigator and Team Members:
• Lee A. Lindquist – MD, MPH, MBA (Pr…
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meps.ahrq.gov/data_files/publications/cb12/cb12.shtml
April 01, 2001 - came primarily from differences in the quantities of drugs purchased rather than differences in the prices … Average prescription medicine price
Medicare
Non-Medicare
Average
$47
$45 … Possible sources of income included annual earnings from wages, salaries, bonuses, tips, and commissions; business
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urine-culturing-notes.docx
April 01, 2022 - The harms that occur can be mistakenly considered an unavoidable “cost of doing business” instead of
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effectivehealthcare.ahrq.gov/sites/default/files/haller.pdf
May 29, 2025 - We're open for business now because
otherwise people forget again.
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/final-report/section2.html
October 01, 2015 - The State was unable to finalize development because neither the State nor the vendor wanted to own the … EHR vendors were reluctant to engage in the demonstration projects, especially because the U.S. … Department of Health and Human Services (HHS) has not mandated that vendors adhere to the Format. … that vendors adhere to the Format. … Overall, lack of vendor participation impeded progress in Category D activities in both States.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Escobar.pdf
February 01, 2005 - research and human
error reduction, because having corrective processes in place may not only be
better business … casual sharing of data from a peer review committee to others internally in the
“normal course of business
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops-asc-webcast-transcript-non-ad.pdf
February 01, 2019 - You can also hire a vendor to do your survey
administration or opt to administer the survey in-house … Even if you are using a vendor there are pros and cons to either one of them. … contract physician, nurses, nurses’ services, technicians,
management, basically everyone including business … Theresa Famolaro
A vendor or management company can definitely submit the data on your behalf. … However, the vendor cannot
sign your data use agreement.
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs016147-rachal-final-report-2009.pdf
January 01, 2009 - Each clinical setting may purchase a system from a
different vendor resulting in record systems which … Forrest General Hospital hired a vendor to build a product to allow
interoperability between the hospital … other hand, described a different systematic problem, incompatible
language or format among software vendors … These three organizations have business agreements that facilitate and support
updating patients’ medical