-
psnet.ahrq.gov/node/49522/psn-pdf
November 01, 2006 - Getting a Good Report Card: Unintended Consequences
of the Public Reporting of Hospital Quality
November 1, 2006
Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of
Hospital Quality. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-…
-
psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis.
February 1, 2023
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
The Cases
Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
-
psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - SPOTLIGHT CASE
When the Lytes Go Out: A Case of Inpatient Cardiac Arrest
Citation Text:
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.…
-
psnet.ahrq.gov/node/49579/psn-pdf
March 21, 2009 - All in the History
March 21, 2009
Fee C. All in the History. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/all-history
Case Objectives
Describe the Emergency Medical Treatment and Active Labor Act (EMTALA) and understand that it
does not apply to transfers to emergency departments from non-acute care faci…
-
psnet.ahrq.gov/web-mm/death-pca
January 06, 2017 - Death by PCA
Citation Text:
Hicks RW. Death by PCA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
-
psnet.ahrq.gov/node/73642/psn-pdf
August 25, 2021 - Sudden Collapse During Upper Gastrointestinal
Endoscopy: Expect the Unexpected
August 25, 2021
Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-
unexpected
…
-
psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - SPOTLIGHT CASE
Errors in Sepsis Management
Citation Text:
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNote X…
-
psnet.ahrq.gov/node/49777/psn-pdf
December 01, 2016 - Suicidal Ideation in the Family Medicine Clinic
December 1, 2016
Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
Case Objectives
Recognize suicide as a major public health problem and the critical role of pri…
-
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…
-
www.ahrq.gov/sites/default/files/2024-01/arora-report.pdf
January 01, 2024 - Final Progress Report: Development and Validation of a Tool to Evaluate Handoff Quality
Final Progress Report
1. Title Page
Title: Development and Validation of a Tool to Evaluate Handoff Quality
Principal Investigator and Team Members:
Vineet Arora, MD, MAPP (Principal Investigator); Jeanne Farnan, MD, MHPE (Co…
-
www.ahrq.gov/sites/default/files/2024-10/mchugh-report.pdf
January 01, 2024 - Final Progress Report: Nurse Staffing Policy, Hospital Occupancy, Market Structure, and Patient Outcomes
Final Progress Report
Title: Nurse Staffing Policy, Hospital Occupancy, Market Structure, and Patient Outcomes
Principal Investigator: Matthew D. McHugh
Team Members: Linda H. Aiken (primary mentor); Jeffrey H.…
-
www.ahrq.gov/sites/default/files/2024-09/kutney-lee-report.pdf
January 01, 2024 - Final Progress Report: Changes in Hospital Care Organization and Outcomes
1. TITLE PAGE
Title: Changes in Hospital Care Organization and Outcomes
Principal Investigator: Ann Kutney-Lee
Team Members: Linda H. Aiken (primary mentor); Jeffrey H. Silber, Mary Naylor, Ivo
Abraham (co-mentors)
Organization: University…
-
psnet.ahrq.gov/node/49506/psn-pdf
March 01, 2006 - The Wet Read
March 1, 2006
Arenson RL. The Wet Read. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/wet-read
Case Objectives
Appreciate the limitations of radiology resident emergency coverage.
Understand the rate of discrepancy between radiology resident preliminary reads and attending
radiologists' fina…
-
psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - Right Patient, Wrong Sample
December 1, 2006
Astion ML. Right Patient, Wrong Sample. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample
The Case
A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. On
the morning of surgery, the patien…
-
psnet.ahrq.gov/node/33770/psn-pdf
August 01, 2014 - In Conversation With… Urmimala Sarkar, MD, MPH
August 1, 2014
In Conversation With… Urmimala Sarkar, MD, MPH. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
Editor's note: Urmimala Sarkar, MD, MPH, is associate professor of medicine at the University of
California, S…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/summary.html
August 01, 2022 - Demonstration Grants Final Evaluation Report
Executive Summary
Previous Page Next Page
Table of Contents
Demonstration Grants Final Evaluation Report
Executive Summary
Detailed Findings
Evaluation Issues
Contributions to Patient Safety and Medical Liability
Lessons Learned From Implement…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
August 01, 2022 - Grand Rounds Presentation
AHRQ Communication and Optimal Resolution Toolkit
Say:
This presentation will introduce you to Communication and Optimal Resolution, or the CANDOR process. Some organizations struggle to improve the way they and their care teams respond to medical harm. The CANDOR process a…
-
www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight06.html
January 01, 2014 - How are CHIPRA quality demonstration States working together to improve the quality of health care for children?
Evaluation Highlight No. 6
Authors: Dana Petersen, Henry Ireys, Grace Ferry, and Leslie Foster
Contents
Key Messages
Background
Findings
Conclusion
Implications
Learn More
Endno…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/overview-ptsoffventilator-slides.pptx
January 01, 2017 - Presentation: Program Overview
Overview:
Getting Patients Off the Ventilator Faster
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-25-EF
January 2017
Overview ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
1
Learning Objectives
After this session, you will be …
-
psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …