-
psnet.ahrq.gov/node/50768/psn-pdf
December 27, 2019 - In Conversation With... Cindy Brach
December 27, 2019
In Conversation With.. Cindy Brach. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-cindy-brach
Editor’s note: Cindy Brach, MPP is a Senior Healthcare Researcher at the Agency for Healthcare
Research and Quality and is the Co-Chair of th…
-
psnet.ahrq.gov/node/33847/psn-pdf
August 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS
August 1, 2017
In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0
Editor's note: Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of
Northwest…
-
psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
August 10, 2019 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable
Citation Text:
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy C…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/spread/spreadnotes.docx
June 02, 2025 - SAY:
The Spread module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit helps all or part of an organization share, tailor, and use the components of a process that have worked well at the unit level. The other CUSP Toolkit modules focus on quality improvement projects at the unit level, where culture i…
-
psnet.ahrq.gov/node/846125/psn-pdf
March 15, 2023 - The I-READI Quality and Safety Framework: Strong
Communications Channels and Effective Practices to
Rapidly Update and Implement Clinical Protocols During a
Time of Crisis
March 15, 2023
https://psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-
and-effective
Summary
…
-
psnet.ahrq.gov/node/49576/psn-pdf
January 01, 2009 - To Transfer or Not to Transfer
January 1, 2009
Pines JM. To Transfer or Not to Transfer. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/transfer-or-not-transfer
Case Objectives
Explore the benefits of the continuity of hospital care.
Understand the rules and regulations behind triage and hospital choice de…
-
psnet.ahrq.gov/node/49592/psn-pdf
October 01, 2009 - Danger in Disruption
October 1, 2009
Fontaine DK. Danger in Disruption. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/danger-disruption
The Case
A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had
metabolic alkalosis (pH = 7.58), and her last peripheral…
-
psnet.ahrq.gov/web-mm/critical-opportunity-lost
February 17, 2017 - Critical Opportunity Lost
Citation Text:
Genzen JR, Signorelli HN. Critical Opportunity Lost. 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 X3 XML EndNote 7 XML…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.272_slideshow.ppt
July 01, 2012 - Spotlight Case July 2008
Spotlight Case
Not-So-Therapeutic Tap
*
*
Source and Credits
This presentation is based on the July 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jeffrey H. Barsuk, MD, MS; Northwestern University Feinberg Scho…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.434_slideshow.ppt
February 01, 2018 - PowerPoint Presentation
Spotlight
Signout Fallout
1
Source and Credits
This presentation is based on the February 2018
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH, Harvard M…
-
psnet.ahrq.gov/node/43443/psn-pdf
August 13, 2014 - Feds stop public disclosure of many serious hospital
errors.
August 13, 2014
O'Donnell J.
https://psnet.ahrq.gov/issue/feds-stop-public-disclosure-many-serious-hospital-errors
This newspaper article reports on changes to publicly reported data on the Hospital Compare Web site.
Several avoidable hospital-acquired …
-
meps.ahrq.gov/survey_comp/hc_survey/2011/MEPS_Cancer_SAQ_R2_Results.shtml
January 01, 2011 - from her surgery and getting
ready to start radiation, commenting that the definition helped her to decide … asked, "Does it
mean health care, support, taking to an appointment, helping understand,
helping decide
-
psnet.ahrq.gov/node/38846/psn-pdf
August 05, 2009 - Seeking a safer surgery: some states crack down on
doctors who perform unregulated outpatient procedures.
August 5, 2009
Landro L.
https://psnet.ahrq.gov/issue/seeking-safer-surgery-some-states-crack-down-doctors-who-perform-
unregulated-outpatient
This article discusses growing legal oversight on outpatient surg…
-
www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/child-maltreatment-interventions-draft-rec-bulletin.pdf
September 25, 2023 - U.S. Preventive Services Task Force Issues Draft Recommendation Statement on Primary Care Interventions to Prevent Child Maltreatment
www.uspreventiveservicestaskforce.org 1
U.S. Preventive Services Task Force Issues Draft Recommendation
Statement on Primary Care Interventions to Prevent
Child Maltreatmen…
-
psnet.ahrq.gov/node/47218/psn-pdf
January 09, 2019 - The accuracy of medical dispatch—a systematic review.
January 9, 2019
Bohm K, Kurland L. The accuracy of medical dispatch - a systematic review. Scand J Trauma Resusc
Emerg Med. 2018;26(1):94. doi:10.1186/s13049-018-0528-8.
https://psnet.ahrq.gov/issue/accuracy-medical-dispatch-systematic-review
Medical dispatch i…
-
psnet.ahrq.gov/node/49646/psn-pdf
February 01, 2012 - Poorly Advanced Directives
February 1, 2012
Anderson WG. Poorly Advanced Directives. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/poorly-advanced-directives
The Case
Cared for at home by his wife and family, an 82-year-old man with multiple chronic medical conditions
described his overall health as decli…
-
psnet.ahrq.gov/node/34749/psn-pdf
January 09, 2017 - Patient Safety and the "Just Culture": A Primer for Health
Care Executives.
January 9, 2017
Marx DA. Patient Safety And The "Just Culture": A Primer For Health Care Executives. New York, NY:
Trustees of Columbia University; 2001.
https://psnet.ahrq.gov/issue/patient-safety-and-just-culture-primer-health-care-execu…
-
psnet.ahrq.gov/node/46398/psn-pdf
June 25, 2018 - Challenges in health care simulation: are we learning
anything new?
June 25, 2018
Henriksen K, Rodrick D, Grace EN, et al. Challenges in Health Care Simulation: Are We Learning Anything
New? Acad Med. 2018;93(5):705-708. doi:10.1097/ACM.0000000000001891.
https://psnet.ahrq.gov/issue/challenges-health-care-simulati…
-
psnet.ahrq.gov/node/45154/psn-pdf
May 25, 2016 - The effect of a program to shorten the decision-to-
delivery interval for emergent cesarean section on
maternal and neonatal outcome.
May 25, 2016
Weiner E, Bar J, Fainstein N, et al. The effect of a program to shorten the decision-to-delivery interval for
emergent cesarean section on maternal and neonatal outcome…
-
psnet.ahrq.gov/node/39922/psn-pdf
October 13, 2010 - What’s past is prologue: organizational learning from a
serious patient injury.
October 13, 2010
Tamuz M, Franchois KE, Thomas EJ. What’s past is prologue: Organizational learning from a serious
patient injury. Saf Sci. 2010;49(1). doi:10.1016/j.ssci.2010.06.005.
https://psnet.ahrq.gov/issue/whats-past-prologue-or…