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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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,…
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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…
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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…
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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…
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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…
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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
…
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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…
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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
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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…
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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…
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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…
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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…