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  1. Lost in Transition | PSNet

    psnet.ahrq.gov/web-mm/lost-transition
    November 17, 2010 - SPOTLIGHT CASE Lost in Transition Citation Text: Beach C. Lost in Transition. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836885/psn-pdf
    May 16, 2022 - Management of Cardiac Arrest in Unconventional Locations. May 16, 2022 Agrawal G, Molla M. Management of Cardiac Arrest in Unconventional Locations. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations The Case Case #1: An 80-year-old man with history of Parkins…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33803/psn-pdf
    January 01, 2015 - In Conversation With… Richard Kronick, PhD February 1, 2014 In Conversation With… Richard Kronick, PhD. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-richard-kronick-phd Editor's note: Dr. Kronick has served as director of the Agency for Healthcare Research and Quality since August 2013 …

  4. Diagnostic Safety Centers of Excellence Grants Awarded in FY 2022 | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/research/grants-2022.html
    August 01, 2025 - Diagnostic Safety Centers of Excellence Grants Awarded in FY 2022 In fiscal year 2022, Congress authorized funding to support AHRQ's research to address failures in the diagnostic process, which may include the establishment of Research Centers of Diagnostic Excellence to develop systems, measures, and new tech…

  5. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? | PSNet

    psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
    March 31, 2021 - Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? Citation Text: Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…

  6. Interdisciplinary teamwork | PSNet

    psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
    September 15, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Interdisciplinary teamwork  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet T…

  7. Module 6: Sustainability: Facilitator Notes | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module6/mod6-facguide.html
    March 01, 2017 - Module 6: Sustainability: Facilitator Notes AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Slide 1: Module 6: Sustainability Say: The Sustainability module of this toolkit helps an organization maintain and sustain a process that has worked well. Slide 2: Objectives Say: In this module we wi…

  8. Barriers Associated with Medication Information Handoffs (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Bayley.pdf
    January 01, 2004 - computer-generated and structured discharge notes, faxed discharge summaries, pharmacy-to-pharmacy communications

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841139/psn-pdf
    December 14, 2022 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. December 14, 2022 Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. PSNet [internet]. 2022. https://psnet.ah…

  10. Delayed Recognition of a Positive Blood Culture | PSNet

    psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
    January 29, 2020 - Delayed Recognition of a Positive Blood Culture Citation Text: Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibT…

  11. Close-Out Report: Improving Resuscitation Team Response to Inpatient Critical Events by Simulation (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/pliego-report.pdf
    January 01, 2024 - Close-Out Report: Improving Resuscitation Team Response to Inpatient Critical Events by Simulation Grant Number: U18 HS16634-01 Grant Period: 9-30-2006 to 10-1-2008 No-cost extension: 10-1-2008 to 9-30-2009 Reporting Period: Close-Out Report Title of Project: Improving Resuscitation Team Response to Inpatient Cri…

  12. Strategy 6K: Cultivating Cultural Competence | Agency for Healthcare Research and Quality

    www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/communication/strategy6kculturalcompetence.html
    March 01, 2020 - Strategy 6K: Cultivating Cultural Competence Contents 6.K.1. The Problem 6.K.2. Interventions    6.K.2.a. Maintaining Complete and Accurate Information on Enrollees    6.K.2.b. Building a Provider Network to Meet the Community’s Linguistic and Cultural Needs    6.K.2.c. Training Providers on Cultural…

  13. A National Web Conference on the Use of Health IT to Improve Care Planning and Communication With Aging Adults - Slides (pdf file)

    digital.ahrq.gov/sites/default/files/docs/hit-aging-adults-slides-071717.pdf
    July 17, 2017 - A National Web Conference on the Use of Health IT to Improve Care Planning and Communication With Aging Adults - Slides 1 A National Web Conference on the Use of Health IT to Improve Care Planning and Communication With Aging Adults Presented by: David H. Gustafson, Ph.D. Charles Safran, M.D., M.S., FACMI Kevi…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854827/psn-pdf
    October 25, 2023 - Beyond the surgical safety checklist: using intraoperative handoff to facilitate team situation awareness in the OR. October 25, 2023 Ramjaun A, Hammond Mobilio M, Wright N, et al. Beyond the surgical safety checklist: using intraoperative handoff to facilitate team situation awareness in the OR. Ann Surg. 2023;278…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47558/psn-pdf
    November 14, 2018 - What we can do about maternal mortality—and how to do it quickly. November 14, 2018 Mann S, Hollier LM, McKay K, et al. What We Can Do about Maternal Mortality - And How to Do It Quickly. New Engl J Med. 2018;379(18):1689-1691. doi:10.1056/NEJMp1810649. https://psnet.ahrq.gov/issue/what-we-can-do-about-maternal-mo…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34649/psn-pdf
    June 11, 2014 - On error management: lessons from aviation. June 11, 2014 Helmreich RL. On error management: lessons from aviation. BMJ . 2000;320(7237):781-785. https://psnet.ahrq.gov/issue/error-management-lessons-aviation In this perspective, the author draws on analogies from aviation to frame the issues of patient safety and …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47761/psn-pdf
    May 22, 2019 - Clinicians' perceptions of opioid error–contributing factors in inpatient palliative care services: a qualitative study. May 22, 2019 Heneka N, Bhattarai P, Shaw T, et al. Clinicians' perceptions of opioid error-contributing factors in inpatient palliative care services: A qualitative study. Palliat Med. 2019;33(4…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73986/psn-pdf
    October 20, 2021 - Fidelity and the impact of patient safety huddles on teamwork and safety culture: an evaluation of the Huddle Up for Safer Healthcare (HUSH) project. October 20, 2021 Lamming L, Montague J, Crosswaite K, et al. Fidelity and the impact of patient safety huddles on teamwork and safety culture: an evaluation of the H…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836994/psn-pdf
    April 27, 2022 - Conversations on diagnostic uncertainty and its management among pediatric acute care physicians. April 27, 2022 Patel SJ, Ipsaro A, Brady PW. Conversations on diagnostic uncertainty and its management among pediatric acute care physicians. Hosp Pediatr. 2022;12(3):317-324. doi:10.1542/hpeds.2021-006076. https://p…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45041/psn-pdf
    September 28, 2016 - Structure and outcomes of interdisciplinary rounds in hospitalized medicine patients: a systematic review and suggested taxonomy. September 28, 2016 Bhamidipati S, Elliott DJ, Justice EM, et al. Structure and outcomes of interdisciplinary rounds in hospitalized medicine patients: A systematic review and suggested …
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