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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846935/psn-pdf
    March 29, 2023 - Maternal Safety and Perinatal Mental Health March 29, 2023 Allen C, Van CM, Mossburg S. Maternal Safety and Perinatal Mental Health . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health Maternal patient safety is a critical aspect of healthcare given the complex pr…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73549/psn-pdf
    July 28, 2021 - Local Anesthesia-Induced Coma During Total Knee Arthroplasty. July 28, 2021 Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty The Case A 61-year-old male patient weighing 57…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49836/psn-pdf
    July 01, 2018 - Primary Workaround, Secondary Complication July 1, 2018 Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication The Case A young adult with a progressive neurological disorder presented to a hospital emerg…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49424/psn-pdf
    November 01, 2003 - Waiting Too Long November 1, 2003 Rosen MA. Waiting Too Long. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/waiting-too-long The Case A 31-year-old gravida 1, para 1 woman presented at 40 weeks in the early stages of labor having received limited prenatal care at an outside clinic. Physical exam performed…
  5. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.338_slideshow.ppt
    January 01, 2015 - PowerPoint Presentation Spotlight Monitoring Fetal Health 1 This presentation is based on the January 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Mark W. Scerbo, PhD, Department of Psychology, Old Dominion University, and Alfred Z. Abuham…
  6. www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3O-Comprehensive_Antibiogram_Toolkit_Phase_3_Implementation.doc
    June 02, 2025 - Comprehensive Antibiogram Toolkit Phase 3 Implementation After the antibiogram has been developed, the nursing home team will need a plan for how the program will be introduced and sustained. Nursing home management should decide if a new policy is required; if so, this must be developed and communicated. Procedures to…
  7. psnet.ahrq.gov/web-mm/near-miss-neonate
    August 15, 2018 - Near Miss With Neonate Citation Text: Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
  8. www.ahrq.gov/hai/cusp/toolkit/content-calls/org-embrace-slides/slides.html
    June 01, 2013 - Organizational Embrace of CUSP to Improve Patient Safety (Slide Presentation) On the CUSP: Stop BSI This PowerPoint slide presentation was shown on March 20, 2012.   Contents Slide 1. The Organizational Embrace of CUSP to Improve Patient Safety Slide 2. Objectives Slide 3. Speakers Slide 4. Holy Cro…
  9. psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx Spotlight When the Indications for Drug Administration Blur Source and Credits • This presentation is based on the June 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Julia Munsch,…
  10. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_sustspreading.pptx
    December 01, 2017 - Presentation: Sustaining and Spreading Surgical Improvments Sustaining and Spreading Surgical Safety Improvements AHRQ Safety Program for Surgery Sustainability AHRQ Pub. No. 16(18)-0004-15-EF December 2017 AHRQ Safety Program for Surgery – Sustainability SAY: This module will cover Sustaining and Spreading Surgic…
  11. www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man1.html
    December 01, 2017 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities Chapter 1. Introduction and Program Overview Previous Page Next Page Table of Contents The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities Chapter 1. Introduction and Program Ove…
  12. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety6.html
    September 01, 2022 - Reinforcing the Value and Roles of Nurses in Diagnostic Safety: Pragmatic Recommendations for Nurse Leaders and Educators References Previous Page Next Page Table of Contents Reinforcing the Value and Roles of Nurses in Diagnostic Safety: Pragmatic Recommendations for Nurse Leaders and Educators I…
  13. psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
    January 01, 2015 - If You Say So: Taking a Syringe at Face Value in the Operating Room Citation Text: Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cita…
  14. psnet.ahrq.gov/web-mm/weak-response
    February 24, 2011 - A "Weak" Response Citation Text: Reisman AB. A "Weak" Response. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  15. www.ahrq.gov/sites/default/files/2025-03/lacson-report.pdf
    January 01, 2025 - Final Progress Report: Factors That Enhance Diagnostic Imaging Safety in the Ambulatory Setting Project Title: Factors that Enhance Diagnostic Imaging Safety in the Ambulatory Setting Principal Investigator: Ronilda Lacson, MD, PHD Team Members: Ramin Khorasani, MD, MPH Ivan Ip, MD, MPH Sonali Desai, MD Allen Ka…
  16. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/safetransitions/safetrans_toolkit.pdf
    December 01, 2017 - related to transitions of care ■ Increase patients’ engagement in their own plan of care ■ Improve communications … individual behaviors and environmental context on patient safety, patient engagement, and provider- patient communications
  17. Autism Surveillance (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/autism_surveillance.pdf
    October 01, 2012 - CER # 26: Therapies for Children with Autism Spectrum Disorders (ASDs) Original release date: April, 2011 Surveillance Report, 1st Assessment: January, 2012 Surveillance Report, 2nd Assessment: October, 2012 Key Findings, 1st Assessment: • For Key Question 1, conclusions regarding intensive early interven…
  18. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt3.pdf
    June 01, 2014 - QDR 2014: Chartbook for Hispanic Health Care, Part 3 Chartbook on Health Care for Hispanics Part 3: Trends in Access and Priorities of the National Quality Strategy 2014 National Healthcare Quality and Disparities Report | 41 PART 3: TRENDS IN ACCESS AND PRIORITIES OF THE NATIONAL QUALITY STRATEGY 2014 QDR Cha…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49658/psn-pdf
    July 01, 2012 - Misleading Complaint July 1, 2012 Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/misleading-complaint The Case A 54-year-old homeless man with a history of alcoholism presented to the emergency department (ED) with complaints of knee problems. The triage nurse docu…
  20. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallspximplsteps.pdf
    June 02, 2025 - Implementation Steps and Timeline - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Implementation Steps and Timeline The goal of On-Time is that a facility staff will incorporate the On-Time reports into day-to-day prevention…