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  1. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  2. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. 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. Copy Citation Format:…
  6. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …
  7. 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…
  8. 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 …
  9. Psn-Pdf (pdf file)

    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…
  10. 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…
  11. 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…
  12. 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 Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL February 9, 2021 …
  13. 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…
  14. Psn-Pdf (pdf file)

    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…
  15. 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…
  16. Lincoln_p1 (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…