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psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - Medication Mix-Up: From Bad to Worse
Citation Text:
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Tacit Handover, Overt Mishap
Citation Text:
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - Continuity Errors in Resident Clinic
Citation Text:
Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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hcup-us.ahrq.gov/datainnovations/clinicaldata/MPinepresentation.jsp
December 01, 2010 - Michael Pine Presentation
An official website of the Department of Health & Human Services
Search All AHRQ Websites
Careers
Contact Us
Espanol
FAQs
Email Updates
…
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psnet.ahrq.gov/node/836839/psn-pdf
March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare
Staff
March 31, 2022
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
Introduction
The…
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psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
January 01, 2021 - Spotlight
Spotlight
Two Cases of Retained Vaginal Packing:
When Writing an Order is Not Enough
Source and Credits
• This presentation is based on the April 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Verna Gibbs, MD
o AHRQ W…
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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…
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www.ahrq.gov/sites/default/files/2024-07/peters-report.pdf
January 01, 2024 - Final Progress Report: How Do Consumers View the Risks of Medical Errors?
FINAL REPORT
Title of Project: How Do Consumers View the Risks
of Medical Errors?
Principal Investigator: Ellen Peters
Team Member: Paul Slovic
Organization: Decision Research
Inclusive Dates of Project: 09/01/2001 – 08/31/2003
Federal …
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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. …
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psnet.ahrq.gov/node/33714/psn-pdf
July 01, 2011 - In Conversation with…William B. Munier, MD, MBA
July 1, 2011
In Conversation with…William B. Munier, MD, MBA. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
Editor's note: William B. Munier, MD, MBA, is the Director of the Center for Quality Improvement and
Pati…
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psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
February 26, 2025 - In Conversation With... James P. Bagian, MD, PE
December 1, 2016
Citation Text:
In Conversation With.. James P. Bagian, MD, PE. PSNet [internet]. 2016.In Conversation With... James P. Bagian, MD, PE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research a…
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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.
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psnet.ahrq.gov/node/49732/psn-pdf
May 01, 2015 - Errors in Sepsis Management
May 1, 2015
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/errors-sepsis-management
Case Objectives
Define sepsis, severe sepsis, and septic shock.
Describe the severe sepsis/septic shock resuscitation bundle.
Recognize commonly encou…
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psnet.ahrq.gov/node/49741/psn-pdf
September 01, 2015 - Abdominal Pain in Early Pregnancy
September 1, 2015
Kilpatrick CC. Abdominal Pain in Early Pregnancy. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy
Case Objectives
Recognize when nausea and vomiting in pregnancy is abnormal.
Identify the most common causes of non-obstetric a…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/translating-cahps-surveys.pdf
January 17, 2017 - Translating CAHPS Surveys
Translating CAHPS® Surveys
Contents
Purpose of this Document ............................................................................................................................. 1
Select Translation Team Members ..................................................................…
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www.ahrq.gov/evidencenow/projects/state/how-to-guide/guide4.html
August 01, 2024 - Developing and Sustaining State-Based Infrastructure To Support Primary Care Quality Improvement
4. Selecting and Delivering Services To Support Quality Improvement
Previous Page Next Page
Table of Contents
Developing and Sustaining State-Based Infrastructure To Support Primary Care Quality Improvem…
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www.ahrq.gov/sites/default/files/2025-04/graber-report.pdf
January 01, 2025 - Final Progress Report: Diagnostic Error in Medicine Conference
Final Progress Report
Grant Number 1R13HS018321-01
Project Period 8/1/2009 - 1/31/2010
Conference: Diagnostic Error In Medicine
PI: Mark L. Graber, MD
SUMMARY: This grant was used in support of “Diagnostic Error in Medicine – 2009,” a 2-day confer…
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psnet.ahrq.gov/node/49645/psn-pdf
February 01, 2012 - E-prescribing: E for error?
February 1, 2012
Ashton EW. E-prescribing: E for error? PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/e-prescribing-e-error
Case Objectives
Define e-prescribing.
Describe ways in which e-prescribing can reduce health care costs.
State how commonly prescription errors occur wit…
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psnet.ahrq.gov/node/49480/psn-pdf
May 01, 2005 - Diagnosing Diagnostic Mistakes
May 1, 2005
McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
Learning Objectives
Understand the biases that may contribute to overcalling medical errors
Describe the impact of conside…
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www.ahrq.gov/hai/tools/mvp/modules/technical/pain-mgmt-slides.html
January 01, 2017 - Evidence Behind Pain, Agitation, and Delirium: Assessments and Sedation Management: Slide Presentation
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients
Evidence Behind Pain, Agitation, and Delirium: Assessments and Sedation Manageme…