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psnet.ahrq.gov/node/846170/psn-pdf
March 15, 2023 - Duplicate Therapies in Retail Pharmacy
March 15, 2023
Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
The Cases
Case 1: A middle-aged man with a past medical history of heart failure with reduced ejection f…
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psnet.ahrq.gov/web-mm/empty-bag
June 01, 2018 - The Empty Bag
Citation Text:
Vincent C. The Empty Bag. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/72835/psn-pdf
March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy
March 10, 2021
In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
Editor’s Note: Libby Hoy, Patient Family Advisor (PFA), is the Founder and CEO of Patient Family
Cente…
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psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms
April 19, 2023 - In Conversation With… Karl Bilimoria, MD, MS
August 1, 2017
Citation Text:
In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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…
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psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures
Citation Text:
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - A Double “Never Event”: Wrong Patient and Wrong Side.
Citation Text:
Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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…
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psnet.ahrq.gov/node/49811/psn-pdf
November 01, 2017 - Delayed Diagnosis of Endocrinologic Emergencies
November 1, 2017
Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
The Cases
Case #1:
A 47-year-old man with a history of hyperthyroidism and h…
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psnet.ahrq.gov/node/49825/psn-pdf
April 01, 2018 - When Patients and Providers Speak Different Languages
April 1, 2018
Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
Case Objectives
Understand the legal and regulatory obligations to prov…
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psnet.ahrq.gov/node/49648/psn-pdf
March 01, 2012 - Postdischarge Follow-Up Phone Call
March 1, 2012
Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
Case Objectives
Understand why preventing readmissions through postdischarge phone calls is important.
Describe evidence su…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
June 02, 2025 - SAY:
The Patient and Family Engagement module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit focuses on an important topic: Making sure patients and their family members understand what is happening during the patient’s hospital stay, are active participants in the patient’s care, and are prepared for…
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www.ahrq.gov/patient-safety/settings/hospital/vtguide/appb2.html
January 01, 2020 - Preventing Hospital-Associated Venous Thromboembolism
Appendix B: Risk Assessment Models, Protocols, and Order Sets (continued)
Previous Page Next Page
Table of Contents
Preventing Hospital-Associated Venous Thromboembolism
Preface
Executive Summary
Chapter 1. The Framework for Improvement
C…
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psnet.ahrq.gov/node/49478/psn-pdf
April 01, 2005 - Compare and Contrast
April 1, 2005
Cho KC, Chertow GM. Compare and Contrast. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/compare-and-contrast
Case Objectives
Define contrast nephropathy (CN)
List risk factors for CN
Implement pharmacologic strategies for CN prophylaxis
Follow an algorithm for CN risk …
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/teamstepps-pocket-guide.pdf
May 01, 2023 - TeamSTEPPS Pocket Guide
Pocket Guide
Team Strategies & Tools
to Enhance Performance
and Patient Safety
Table of Contents
TeamSTEPPS® ................................................. 1
Framework and Competencies ........................1
Key Skills .........................................................…
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psnet.ahrq.gov/node/74691/psn-pdf
January 01, 2021 - U.S. Department of Veterans Affairs Medical Center,
Houston, TX, and Baylor College of Medicine Revised
Safer Diagnosis (Safer Dx) Instrument
January 26, 2022
https://psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-
college-medicine
Summary
The Revised Safer Dx Instr…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-091013.ppt
January 01, 2010 - Reducing Unecessary Urinary catheter Use in the Emergency Department: How to Implement the Process
The Emergency Department & Catheter Insertions
*
Mohamad Fakih, MD, MPH
St. John Hospital and Medical Center
Lisa Wolf, PhD, RN, CEN, FAEN
Emergency Nurses Association (ENA)
Jeremiah Schuur, MD, MHS, FACEP
Brig…
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www.ahrq.gov/sites/default/files/2024-07/walker-report.pdf
January 01, 2024 - Final Progress Report: Regional Approach for THQIT in Rural Settings - Planning
FINAL PROGRESS REPORT
Regional Approach for THQIT in Rural Settings
AHRQ Grant: 1 P20 HS015457-01
Project Title: “Regional Approach for THQIT in Rural Settings – Planning”
Principal Investigator: James M. Walker, MD
Team Members:
M…
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psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart
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June 12, 2020
…
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www.ahrq.gov/sites/default/files/wysiwyg/chsp/news-and-events/events/webinars/chsp-webinar-slides-011221.pdf
January 12, 2021 - Advancing Understanding of Health Care Delivery Using the AHRQ Compendium of U.S. Health Systems
Advancing Understanding of
Health Care Delivery
Using the Compendium of
U.S. Health Systems
January 12, 2021
Presenters
Genna Cohen
Mathematica
Michael Furukawa
Agency for Healthcare
Research and Quality
David J…
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psnet.ahrq.gov/node/49771/psn-pdf
July 01, 2016 - Unintended Consequences of CPOE
October 1, 2016
Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
Case Objectives
Explain how technology, including computerized provider order entry, can transform, rather than
eliminate, hazards.
Recogni…
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Unexplained Apnea Under Anesthesia
February 1, 2003
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
Case Objectives
Clinical Objectives
List the causes of prolonged apnea in the operating room
Describe the steps in management …