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  1. Final Progress Report: Comprehensive Pediatric Hypertension Diagnosis and Management (pdf file)

    www.ahrq.gov/sites/default/files/2025-03/rinke2-report.pdf
    January 01, 2025 - Final Progress Report: Comprehensive Pediatric Hypertension Diagnosis and Management 1. TITLE PAGE Comprehensive Pediatric Hypertension Diagnosis and Management Principal Investigator: Michael L. Rinke, MD, PhD Co-Investigators: David G. Bundy, MD, MPH, Tammy M. Brady, MD, PhD, Beth Tarini, MD, Katherine E. Twomb…

  2. Saworksheet (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/saworksheet.docx
    June 02, 2025 - On-Time Pressure Ulcer Prevention Self-Assessment Worksheet for Pressure Ulcer The Self-Assessment Worksheet is designed to help staff review how they currently identify residents who have experienced a change in pressure ulcer risk, how they determine if new clinical interventions are needed, and how they determine w…

  3. Critical care checklists, the Keystone Project, and the Office for Human Research Protections: a case for streamlining the approval process in quality-improvement research. | PSNet

    psnet.ahrq.gov/issue/critical-care-checklists-keystone-project-and-office-human-research-protections-case
    May 04, 2014 - Commentary Critical care checklists, the Keystone Project, and the Office for Human Research Protections: a case for streamlining the approval process in quality-improvement research. Citation Text: Savel RH, Goldstein EB, Gropper MA. Critical care checklists, the Keystone Project, an…

  4. Intensive care units, communication between nurses and physicians, and patients' outcomes. | PSNet

    psnet.ahrq.gov/issue/intensive-care-units-communication-between-nurses-and-physicians-and-patients-outcomes
    May 28, 2008 - Study Intensive care units, communication between nurses and physicians, and patients' outcomes. Citation Text: Manojlovich M, Antonakos CL, Ronis DL. Intensive care units, communication between nurses and physicians, and patients' outcomes. Am J Crit Care. 2009;18(1):21-30. doi:10.403…

  5. Compendium of Strategies to Prevent HAIs in Acute Care Hospitals 2014. | PSNet

    psnet.ahrq.gov/issue/compendium-strategies-prevent-hais-acute-care-hospitals-2014
    July 02, 2009 - Special or Theme Issue Compendium of Strategies to Prevent HAIs in Acute Care Hospitals 2014. Citation Text: Compendium of Strategies to Prevent HAIs in Acute Care Hospitals 2014. Infect Control Hosp Epidemiol. 2014;35(Suppl 2):s1-s178;35:460-463;797-801. Copy Citation …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47559/psn-pdf
    November 14, 2018 - Changes in prevalence of health care-associated infections in U.S. hospitals. November 14, 2018 Magill SS, O'Leary E, Janelle SJ, et al. Changes in Prevalence of Health Care-Associated Infections in U.S. Hospitals. N Engl J Med. 2018;379(18):1732-1744. doi:10.1056/NEJMoa1801550. https://psnet.ahrq.gov/issue/change…

  7. Complications of Vascular Access Procedures in Patients with Kidney Disease | PSNet

    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. …

  8. Hospital Expands Use of AHRQ’s QI Toolkit To Improve Patient Safety Measures Prioritized by Medicare (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/standalone_psi_casestudy.pdf
    June 02, 2025 - Hospital Expands Use of AHRQ’s QI Toolkit To Improve Patient Safety Measures Prioritized by Medicare Hospital Expands Use of AHRQ’s QI Toolkit To Improve Patient Safety Measures Prioritized by Medicare Abstract Hospital Harborview Medical Center (HMC), a large, level I trauma center in Seattle, Washington L…

  9. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.88_slideshow.ppt
    March 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case March 2005 The Hidden Mystery Source and Credits This presentation is based on the March 2005 AHRQ WebM&M Spotlight Case in Hospital Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Douglas D. Br…

  10. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.85_slideshow.ppt
    March 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case March 2005 The Hidden Mystery Source and Credits This presentation is based on the March 2005 AHRQ WebM&M Spotlight Case in Hospital Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Douglas D. Br…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49832/psn-pdf
    June 01, 2018 - Febrile Neutropenia and an Almost Fatal Medication Error June 1, 2018 Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error The Case A 33-year-old woman with recently diagnosed acute …

  12. Hemolysis Holdup | PSNet

    psnet.ahrq.gov/web-mm/hemolysis-holdup
    July 03, 2016 - Hemolysis Holdup Citation Text: Lehman CM. Hemolysis Holdup. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49757/psn-pdf
    April 01, 2016 - Situational Awareness and Patient Safety April 1, 2016 Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety The Case A 40-year-old woman with a history of cirrhosis and known esophageal varices was admitted to the hospit…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49635/psn-pdf
    September 01, 2011 - Central, not Epidural September 1, 2011 Simmons D. Central, not Epidural. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/central-not-epidural The Case A 55-year-old man with lung cancer recently had the lower lobe of his left lung removed. Post-operatively, he was awake, alert, and oriented to time, place,…

  15. Not-So-Therapeutic Tap | PSNet

    psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
    December 01, 2014 - SPOTLIGHT CASE Not-So-Therapeutic Tap Citation Text: Barsuk JH. Not-So-Therapeutic Tap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45533/psn-pdf
    November 02, 2016 - Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach. November 2, 2016 Power M, Brewster L, Parry G, et al. Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach. BMJ Open. 2016;6(9):e011886. doi:10.1136/bmjopen-2016-…

  17. Embracing errors in simulation-based training: the effect of error training on retention and transfer of central venous catheter skills. | PSNet

    psnet.ahrq.gov/issue/embracing-errors-simulation-based-training-effect-error-training-retention-and-transfer
    May 23, 2013 - Study Embracing errors in simulation-based training: the effect of error training on retention and transfer of central venous catheter skills. Citation Text: Gardner AK, Abdelfattah K, Wiersch J, et al. Embracing Errors in Simulation-Based Training: The Effect of Error Training on Retent…

  18. A hybrid methodology for modeling risk of adverse events in complex health-care settings. | PSNet

    psnet.ahrq.gov/issue/hybrid-methodology-modeling-risk-adverse-events-complex-health-care-settings
    November 11, 2015 - Study A hybrid methodology for modeling risk of adverse events in complex health-care settings. Citation Text: Kazemi R, Mosleh A, Dierks M. A Hybrid Methodology for Modeling Risk of Adverse Events in Complex Health-Care Settings. Risk Anal. 2017;37(3):421-440. doi:10.1111/risa.12702. …

  19. Improving patient safety in intensive care units in Michigan. | PSNet

    psnet.ahrq.gov/issue/improving-patient-safety-intensive-care-units-michigan
    February 17, 2011 - Study Classic Improving patient safety in intensive care units in Michigan. Citation Text: Pronovost P, Berenholtz SM, Goeschel CA, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23(2):207-212. doi:10.1016/j.jcrc.2007.09…

  20. The wisdom and justice of not paying for "preventable complications." | PSNet

    psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-preventable-complications
    January 22, 2014 - Commentary Classic The wisdom and justice of not paying for "preventable complications." Citation Text: Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.1…
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