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  1. Psn-Pdf (pdf file)

    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-…
  2. Psn-Pdf (pdf file)

    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) …
  3. 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.…
  4. Psn-Pdf (pdf file)

    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…
  5. 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…
  6. Psn-Pdf (pdf file)

    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 …
  7. 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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. 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…
  11. 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.…
  12. 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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. 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…
  17. 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…
  18. 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…
  19. 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 …
  20. Psn-Pdf (pdf file)

    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 …