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psnet.ahrq.gov/node/49549/psn-pdf
December 06, 2007 - Elopement
December 1, 2007
Gerardi D. Elopement. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/elopement
Case Objectives
Define elopement and differentiate it from wandering and leaving against medical advice.
Identify leading contributors to elopement events.
Describe strategies for preventing elopement…
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psnet.ahrq.gov/node/49608/psn-pdf
August 01, 2010 - Emergent Triage Miss
August 1, 2010
Travers D. Emergent Triage Miss. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/emergent-triage-miss
The Case
A 42-year-old woman presented to a busy urban emergency department (ED) and approached the triage
nurse. The patient told the triage nurse that she had "3 days o…
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/implementation-guides/implementation-guide1/impguide1step3.html
March 01, 2019 - Step 3: Build the Stakeholder Group Structure
Implementation Guide Number 1
This Implementation Guide includes suggested steps and tips for implementing initiatives for improving child health care quality from the CMS-funded national evaluation of the Children’s Health Insurance Program Reauthorization Act of…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-removal-notes.docx
April 01, 2022 - Prompting Removal of Unnecessary Indwelling Urinary Catheters Facilitator Notes
CAUTI Module:
Indwelling Urinary Catheter Removal
Facilitator Guide
Slide Number and Image
This module, titled “Indwelling Urinary Catheter Removal,” is part of the Agency for Healthcare Research and Quality’s Safety Program for In…
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digital.ahrq.gov/program-overview/research-reports/2021-year-review/research-overview
January 01, 2021 - Research Overview
Digital healthcare knowledge and tools can enhance the efforts of patients, clinicians, and health systems working to improve healthcare quality and safety. AHRQ’s DHR program funds research to create actionable findings on what and how digital healthcare works best for t…
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psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
January 03, 2017 - SPOTLIGHT CASE
Treatment Challenges After Discharge
Citation Text:
Coffey C. Treatment Challenges After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
Google Scholar Bib…
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psnet.ahrq.gov/node/49573/psn-pdf
January 01, 2009 - Dangerous Shift
November 1, 2008
Patterson ES. Dangerous Shift. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/dangerous-shift
Case Objectives
Review the evidence base on erroneous actions related to shift changes.
Understand the limits of standardizing handoffs in preventing errors at shift change.
Expla…
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digital.ahrq.gov/ahrq-funded-projects/develop-and-validate-health-it-safety-measures-capture-violations-five-rights
January 01, 2023 - Develop and Validate Health IT Safety Measures To Capture Violations of the Five Rights of Medication Safety
Project Final Report ( PDF , 706.51 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/podcasts/Teamwork_in_QI_2012_02_01_Transcript.pdf
January 01, 2012 - Teamwork in Quality Improvement
Teamwork in Quality Improvement
February 2012 Podcast
Speaker
Marjie Harbrecht, CEO, HealthTeamWorks
Moderator
Carla Zema, Consultant, CAHPS User Network; Assistant Professor of Economics and Health Policy,
Saint Vincent College
Presentation Available
https://www.ca…
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www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/current-processes-refining-evidence-based-recommendation-development
January 01, 2014 - Current Processes: Refining Evidence-based Recommendation Development
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Print
Table of Contents
Preface
Introduction
Types of Recommendations
Types of Evidence Reviews
Co…
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Jaenic Lee, MD Josh Fernel…
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psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
January 01, 2024 - Spotlight
Spotlight
A Fatal Twist in Pseudohyperkalemia
1
Source and Credits
This presentation is based on the August 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Le…
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psnet.ahrq.gov/web-mm/worst-headache
July 01, 2016 - The Worst Headache
Citation Text:
Edlow JA. The Worst Headache. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
November 15, 2023 - Mother's Milk, but Whose Mother?
Citation Text:
Dougherty D. Mother's Milk, but Whose Mother?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Neuspiel_43.pdf
March 05, 2008 - Improving Error Reporting in Ambulatory Pediatrics with a Team Approach
Improving Error Reporting in Ambulatory
Pediatrics with a Team Approach
Daniel R. Neuspiel, MD, MPH; Margo Guzman, RN, MSN; Cari Harewood, MPA
Abstract
Objective: We aimed to determine the effectiveness of team-based reporting, system…
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psnet.ahrq.gov/web-mm/result-stopped-here
December 01, 2006 - The Result Stopped Here
Citation Text:
Astion ML. The Result Stopped Here. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists
Citation Text:
Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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digital.ahrq.gov/sites/default/files/docs/publication/modeling-pcmh-principles-attributes-patient-experiences-narrative-report.pdf
November 01, 2014 - This panel had representatives from policymakers, health IT
vendors, provider organizations, and patient … American College of Physicians Provider
Terry McGeeney, MD TransforMED Provider
David Nace, MD McKesson Vendor … Bob Phillips, MD American Academy of Family Physicians Provider
Rick Ratliff Accenture Vendor
Cris … Even during business hours, the PCMH practice must support
emergency access. … From these components, IT use cases and test
cases can be constructed to support health IT vendors to
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www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-8.html
July 01, 2019 -
2
Sterilization Techs
7
Certified Dental Laboratory Technicians
FTE
Business … An external vendor does monthly patient telephone surveys about medical, dental, and Wesley Nurse interventions
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effectivehealthcare.ahrq.gov/sites/default/files/crosscutting-horizon-scan-high-impact-1406.pdf
June 01, 2014 - sector whose experience reflects clinical practice, clinical research, health care delivery, health
business … identified in the system by
the perspective they bring (e.g., clinical, research, health systems, health business … establish and maintain a postdischarge clinic vary depending on the institution or health
system’s business … patients ≥18 years old undergoing colonoscopy and esophagogastroduodenoscopy
(EGD) procedures.”7 Sales … sensor as a Class II device
subject to special controls.32,33 The entire system is now available for sale