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psnet.ahrq.gov/web-mm/not-miscarriage
June 01, 2005 - Not a Miscarriage
Citation Text:
Learman LA. Not a Miscarriage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - Is It Safe to Be Direct?
Citation Text:
Kulkarni NS, Williams M. Is It Safe to Be Direct?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - Lapse in Antibiotics Leads to Sepsis
October 1, 2016
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
The Case
A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal
pain, fevers, and short…
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psnet.ahrq.gov/node/853772/psn-pdf
September 27, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not
Interchangeable
September 27, 2023
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
The Case
A fourteen-ye…
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psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
August 30, 2023 - Strategies to Improve Organizational Health Literacy.
Citation Text:
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/misleading-complaint
December 01, 2009 - Misleading Complaint
Citation Text:
Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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digital.ahrq.gov/ahrq-funded-projects/improving-population-health-through-enhanced-targeted-regional-decision-support
January 01, 2023 - Improving Population Health Through Enhanced Targeted Regional Decision Support
Project Final Report ( PDF , 1.05 MB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily repr…
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www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/measures/measure-2.html
November 01, 2017 - Established Child Health Care Quality Measures—CAHPS
Child Health Care Quality Toolbox
The Child Health Toolbox contains concepts, tips, and tools for evaluating the quality of health care for children.
Contents
Expanded CAHPS 3.0 Child Survey
Children with Chronic Conditions
Screener Questions
…
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psnet.ahrq.gov/node/50843/psn-pdf
January 29, 2020 - Incomplete Orders for Hypertonic Saline to Treat
Hyponatremia
January 29, 2020
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet].
2020.
https://psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
The Case
A 54-year-old man was brought t…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/leveraging-cultural-change-080814.pptx
January 01, 2013 - Slide 1
Leveraging Cultural Change to Reduce Urinary Catheter Use
1
Linda Greene, RN,MPS,CIC
Manager Infection Prevention
Highland Hospital
Jennifer Tuttle, RN, MSNEd
Adult Critical Care Unit
Tucson Medical Center
Learning Objectives
Describe the way in which improvement in the clinical culture can facilitate e…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Learning From Defects: Applying the “Swiss cheese model” of System Failure
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
Slide Title and Commentary
Slide Number and Slide
Learning From Defects: Applying the “Swiss C…
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psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
October 30, 2024 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates
Save
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February 9, 2021
…
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digital.ahrq.gov/ahrq-funded-projects/past-initiatives/ambulatory-safety-and-quality-program
January 01, 2023 - Ambulatory Safety and Quality Program (2007-2013)
Overview
The purpose of the Agency for Healthcare Research and Quality's (AHRQ's) Ambulatory Safety and Quality (ASQ) program is to improve the safety and quality of ambulatory health care in the United States. The program includes four h…
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psnet.ahrq.gov/node/836791/psn-pdf
August 21, 2024 - TeamSTEPPS for Diagnosis Improvement.
August 21, 2024
TeamSTEPPS for Diagnosis Improvement.
https://psnet.ahrq.gov/issue/teamstepps-diagnosis-improvement
The recognition of diagnosis as a team activity is energizing new diagnostic process initiatives. Building on
the established TeamSTEPPS® principles, this new Te…
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digital.ahrq.gov/location/usa-la-franklin
January 01, 2023 - USA, LA, Franklin
Service Integration
Description
Built an integrated communications system with area hospitals, clinics, and service providers in St. Mary Parish, Iberia Parish, and Terrebonne Parish that will support chronic disease management and improve patient safety. Aut…
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effectivehealthcare.ahrq.gov/sites/default/files/lincoln_p1.pdf
January 01, 2010 - Lincoln_p1
Slide 1: Realizing
the Promise of Web 2.0 Marketing
and Dissemination of
Patient-‐Centered
Health Research
Jane
Lincoln
Project Manager
Social Impact -‐ AARP
Slide 2: Untitled
http://www.youtube.com/watch?v=h-‐8PBx7isoM
Slide 3:
Realizing
the Promise of Web 2.0 Marketing
and Dis…
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psnet.ahrq.gov/node/44226/psn-pdf
November 03, 2015 - The Patient Survival Handbook.
November 3, 2015
Powell SM, Stone RD. Peachtree City, GA: Synensis; 2015.
https://psnet.ahrq.gov/issue/patient-survival-handbook
Engaging patients in their care is increasingly advocated as a way to improve safety. This book
recommends actions for patients and families to reduce risk…
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psnet.ahrq.gov/node/74766/psn-pdf
June 24, 2024 - Patient handoffs.
June 24, 2024
Arora V, Farnan J. UpToDate. June 24, 2024.
https://psnet.ahrq.gov/issue/patient-handoffs-0
The change of an inpatient’s location or handoffs between teams can fragment care due to communication,
information, and knowledge gaps. This review examines in-patient transition safety issu…
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psnet.ahrq.gov/node/46039/psn-pdf
April 05, 2017 - Retained lumbar catheter tip.
April 5, 2017
DeLancey JO, Barnard C, Bilimoria KY. Retained Lumbar Catheter Tip. JAMA. 2017;317(12):1269-1270.
doi:10.1001/jama.2017.1713.
https://psnet.ahrq.gov/issue/retained-lumbar-catheter-tip
Retained surgical items are considered a sentinel event. Discussing an incident involvi…
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psnet.ahrq.gov/node/42403/psn-pdf
August 02, 2015 - Encouraging patients to ask questions: how to overcome
"white-coat silence."
August 2, 2015
Judson TJ, Detsky AS, Press MJ. Encouraging patients to ask questions: how to overcome "white-coat
silence". JAMA. 2013;309(22):2325-6. doi:10.1001/jama.2013.5797.
https://psnet.ahrq.gov/issue/encouraging-patients-ask-quest…