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9341. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49628/psn-pdf
      June 01, 2011 - Routine Goes Awry June 1, 2011 Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/routine-goes-awry The Case A 6-year-old girl with a history of asthma and chronic adenotonsillitis was referred to a surgeon and scheduled for a tonsillectomy and adenoidectomy. She was in ot…

9342. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
      January 01, 2020 - PowerPoint Presentation Spotlight A ʺReflexiveʺ Diagnosis in Primary Care 1 This presentation is based on the April 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John Betjemann, MD, and S. Andrew Josephson, MD, University of California, San…

9343. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73412/psn-pdf
      August 01, 2022 - “Behavioral Health Vital Signs” Initiative Increases Patient Education and Disclosure about Interpersonal Violence (IPV) June 30, 2021 https://psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and- disclosure Summary The Behavioral Health Vital Signs (BHVS) screener i…

9344. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49650/psn-pdf
      March 01, 2012 - Turn the Other Cheek March 1, 2012 Starling J. Turn the Other Cheek. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/turn-other-cheek The Case A 56-year-old man underwent two skin biopsies to evaluate clinically concerning lesions. The first biopsy was diagnostic for squamous cell carcinoma (SCC) and docume…

9345. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49740/psn-pdf
      August 21, 2015 - Baffled by Botulinum Toxin August 21, 2015 Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/baffled-botulinum-toxin The Case A 5-year-old boy with a history of transverse myelitis with resultant spasticity of both lower extremities, gait abnormalities, neurogeni…

9346. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49595/psn-pdf
      December 01, 2009 - "Superficial" Report Leads to "Deep" Problem December 1, 2009 Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem The Case A 35-year-old woman presented to the emergency department (ED) complaining of left foot and an…

9347. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49727/psn-pdf
      March 01, 2015 - Critical Opportunity Lost March 1, 2015 Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/critical-opportunity-lost The Case A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. She reported eating a heavy dinner the pre…

9348. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49814/psn-pdf
      December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation Mishap December 1, 2017 Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap The Case A 63-year-old man with a history of coronary…

9349. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49438/psn-pdf
      March 05, 2004 - OR Peeping March 1, 2004 Mackenzie CF. OR Peeping. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/or-peeping The Case A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete spontaneous abortion (miscarriage). At this community hospital, a new operating room (OR) su…

9350. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33876/psn-pdf
      August 01, 2018 - Building a Safety Program in a Vast Health Care Network March 1, 2019 Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network Perspective Background As hospital-based health care in the United …

9351. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49507/psn-pdf
      April 01, 2006 - Is the "Surgical Personality" a Threat to Patient Safety? April 1, 2006 Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety? PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety Case Objectives Describe the myth of the "surgical personality" Identify featu…

9352. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49456/psn-pdf
      July 12, 2004 - Glucose Roller Coaster July 1, 2004 Sharpe B. Glucose Roller Coaster. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/glucose-roller-coaster The Case A 71-year-old woman with congestive heart failure was admitted to the hospital. Her medical history was significant for dialysis-dependent, end-stage kidney d…

9353. Spotlight (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.443_slideshow.ppt
      May 01, 2018 - Spotlight Spotlight Out of Sight, Out of Mind: Out-of-Office Test Result Management 1 Source and Credits This presentation is based on the May 2018 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Eric Poon, MD, MPH, Duke University School o…

9354. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49805/psn-pdf
      September 01, 2017 - The Forgotten Radiographic Read September 1, 2017 Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/forgotten-radiographic-read The Case A 60-year-old woman with peripheral artery disease and chronic mesenteric ischemia was admitted for management of inferior…

9355. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49742/psn-pdf
      September 01, 2015 - A Fumbled Handoff to Inpatient Rehab September 1, 2015 Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab The Case An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…

9356. Spotlight Case (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
      August 01, 2012 - Spotlight Case Spotlight Case No News May Not Be Good News 1 2 Source and Credits This presentation is based on the August 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Carlton R. Moore, MD, MS; University of North Carolina, School of Medicin…

9357. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49515/psn-pdf
      July 01, 2006 - Over Not So Easy July 1, 2006 Cucina R. Over Not So Easy. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/over-not-so-easy The Case A 62-year-old woman with end-stage liver disease was hospitalized for recurrent variceal bleeding. On admission, she reported allergies to a number of medications as well as a …

9358. AHRQ Works: Building Bridges Between Research and Practice (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cpi/about/impact/ahrq-works.pdf
      April 01, 2017 - AHRQ Works: Building Bridges Between Research and Practice Accelerating learning and innovation in health care delivery is what AHRQ does—every day. AHRQ tools take the “what” and translate it into the “how” by providing research-backed, practical tools that doctors and nurses can use to improve care. This doc…

9359. CAHPS Child Hospital Survey-Using Data and New Narrative Items - Overview (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-ch-hospital-webcast-122223-toomey.pdf
      December 01, 2022 - CAHPS Child Hospital Survey-Using Data and New Narrative Items - Overview OVERVIEW OF THE CHILD HCAHPS SURVEY Sara Toomey, MD, MPhil, MPH, MSc Chief Safety and Quality Officer, SVP Chief Experience Officer Director/PI, Center of Excellence for Pediatric Quality Measurement Boston Children’s Hospital Child HCAH…

9360. Section 2: Explanation of Key Concepts and Tools | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/situation/tools/index.html
      June 01, 2023 - Section 2: Explanation of Key Concepts and Tools This section contains explanations and illustrations to help you better understand and appreciate the importance of situation monitoring and TeamSTEPPS situation monitoring tools. If you teach this content or want additional insights on how the material can be mo…