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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dx-journey-mr-kane.pptx
June 02, 2025 - Journey of Mr. Kane
The Diagnostic Journey of
Mr. Kane
TeamSTEPPS® for Diagnosis Improvement
Narrator: This story is about the diagnostic journey of Mr. Kane. The story outlines several areas where communication failures led to missed and delayed diagnosis that contributed to Mr. Kane’s death. The story is told fro…
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psnet.ahrq.gov/node/49537/psn-pdf
June 01, 2007 - Beeline to Spine
June 1, 2007
Smetana GW. Beeline to Spine. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/beeline-spine
Case Objectives
Understand the elements of preoperative medical evaluation.
Appreciate the limited role for preoperative laboratory testing.
Appreciate the importance of communication a…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/009-antibiotic-stewardship-guide.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
Antibiotic Stewardship and MRSA Reduction
ICU & Non-ICU
Slide Title and Commentary
Slide Number and Slide
Antibiotic Stewardship and MRSA Reduction
SAY:
Welcome to this presentation on antibiotic stewardship as part of an overall approach to preventing MRSA in ICU and non-IC…
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psnet.ahrq.gov/node/838222/psn-pdf
September 28, 2022 - In Conversation With... Jack Westfall, MD, MPH
September 28, 2022
In Conversation With.. Jack Westfall, MD, MPH. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
Editor’s note: Jack Westfall, MD, MPH, is a retired professor from the University of Colorado School of
Medic…
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psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD
August 1, 2016
Also Read an Essay
Citation Text:
In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Heal…
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psnet.ahrq.gov/node/73398/psn-pdf
June 30, 2021 - In Conversation With... Anjali Joseph, PhD, EDAC and
Molly M. Scanlon, PhD, FAIA, FACHA
June 30, 2021
In Conversation With.. Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-
…
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight01.html
March 01, 2019 - How are CHIPRA demonstration States approaching practice-level quality measurement and what are they learning?
Evaluation Highlight No. 1
The National Evaluation of the CHIPRA Quality Demonstration Grant Program
Authors: Grace A. Ferry, Henry T. Ireys, Leslie Foster, Kelly J. Devers, and Lauren Smith
This…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/vaesurveillance-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Ventilator-Associated Event Surveillance
SAY:
This module will focus on ventilator-associated event surveillance and how it can be used in your unit.
Slide 1
Learning Objectives
SAY:
After this se…
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psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
January 01, 2024 - Spotlight
Spotlight
Missed Connection: A Case of Inadequate ECG
Oversight in Cardiac Surgery
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Christian Bohringer, MBBS, …
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psnet.ahrq.gov/node/843051/psn-pdf
February 01, 2023 - Respiratory Distress after Neck Surgery: Two Cases of
Postoperative Cervical Hematoma.
February 1, 2023
Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical
Hematoma. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-…
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psnet.ahrq.gov/node/865429/psn-pdf
April 24, 2024 - Missed Connection: A Case of Inadequate ECG Oversight
in Cardiac Surgery
April 24, 2024
Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac
Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery…
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - SPOTLIGHT CASE
Too Many Cooks in the Kitchen
Citation Text:
Dutton RP. Too Many Cooks in the Kitchen. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
Copy Citation
Format:
Google Scholar BibTeX EndNote X…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.pdf
May 01, 2017 - Implement Teamwork and Communication for Perinatal Safety
AHRQ Safety Program for Perinatal Care
Implement Teamwork and Communication for Perinatal Safety
AHRQ Publication No. 17-0003-3-EF
May 2017
SAY:
The Implement Teamwork and
Communication module of the AHRQ Safety
Program for Perinatal Care will help yo…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving.pptx
May 01, 2017 - Improving Communication and Teamwork in the Surgical Environment
Improving Communication and Teamwork in the Surgical Environment Module
AHRQ Safety Program for Ambulatory Surgery
AHRQ Pub. No. 16(17)-0019-2-EF
May 2017
Communication and Teamwork | ‹#›
AHRQ Safety Program for Ambulatory Surgery
1
Objectives
…
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www.ahrq.gov/research/findings/final-reports/ptmgmt/design2.html
July 01, 2018 - Patient Self-Management Support Programs: An Evaluation
Design Options for a Self-Management Support Program (continued)
Previous Page Next Page
Table of Contents
Patient Self-Management Support Programs: An Evaluation
Acknowledgments
Introduction and Purpose
Summary
Background
Methodology…
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psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - SPOTLIGHT CASE
Despite Clues, Failed to Rescue
Citation Text:
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibTeX EndN…
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - SPOTLIGHT CASE
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
Citation Text:
Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cap-toolkit/cap_imptoolkit.pdf
January 01, 2018 - Community-Acquired Pneumonia Clinical Decision Support Implementation Toolkit Handbook
Community-Acquired
Pneumonia Clinical
Decision Support
Implementation
Toolkit
Handbook
1
Table of Contents
Introduction .................................................................................................…
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www.ahrq.gov/policymakers/chipra/overview/background/methods.html
December 01, 2009 - Background Report for the Request for Public Comment on Initial, Recommended Core Set of Children's Healthcare Quality Measures for Voluntary Use by Medicaid and CHIP Programs
Background Report on request for public comment on initial, recommended core set of Children's Healthcare Quality Measures for voluntary…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0129references.pdf
October 23, 2013 - References
1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the
Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418–1428.
2. Wick EC, Shore AD, Hirose K, Ibrahim AM, Gearhart SL, Efron J, Weiner JP, Makary MA.
Readmission rates and cost following colorectal surgery. Dis …