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  1. Breathe Easy: Safe Tracheostomy Management | PSNet

    psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
    June 07, 2023 - Breathe Easy: Safe Tracheostomy Management Citation Text: Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar Bib…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49687/psn-pdf
    August 21, 2013 - Emergency Error August 21, 2013 Symons NRA. Emergency Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/emergency-error Case Objectives State that emergency surgery is high risk and has high mortality. Appreciate that emergency laparotomy is a particularly high-risk procedure with a high likelihood of …

  3. AHRQ Step Up Challenge Summary (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/ahrq-step-up-app-challenge-summary-2019.pdf
    January 01, 2019 - AHRQ Step Up Challenge Summary 1 CHALLENGE SUMMARY 12 CHALLENGE SUMMARY AHRQ Step Up App Challenge Prepared for: Agency for Healthcare Research and Quality 5600 Fishers Lane Rockville, MD 20857 www.ahrq.gov Contract No. HHSA29032001 Prepared by: Sensis 500 Penn Street NE Washington, DC 20…

  4. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room | PSNet

    psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
    July 28, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room Citation Text: Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33622/psn-pdf
    November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP November 1, 2005 In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp Editor's Note: Dr. Berwick is President and Chief Executive Officer of the Institute for Healthcare I…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33717/psn-pdf
    September 01, 2011 - Incident Reporting: More Attention to the Safety Action Feedback Loop, Please September 1, 2011 Nuckols TK. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73650/psn-pdf
    August 25, 2021 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax August 25, 2021 Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumoth…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841469/psn-pdf
    December 14, 2022 - Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. December 14, 2022 Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-mi…

  9. Liposuction Gone Awry | PSNet

    psnet.ahrq.gov/web-mm/liposuction-gone-awry
    July 01, 2003 - Liposuction Gone Awry Citation Text: Yates JA. Liposuction Gone Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49568/psn-pdf
    September 01, 2008 - Failure to Latch September 1, 2008 Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/failure-latch The Case The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to breastfeeding exclusively for 6 months. However, early br…

  11. Danger in Disruption | PSNet

    psnet.ahrq.gov/web-mm/danger-disruption
    July 29, 2020 - Danger in Disruption Citation Text: Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…

  12. CUSP Toolkit Spread Facilitator Notes | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cusp/modules/spread/notes.html
    December 01, 2012 - CUSP Toolkit Spread Facilitator Notes CUSP Toolkit The Spread module of the CUSP Toolkit helps an organization share, tailor, and implement 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…

  13. Cuestionario sobre la de seguridad de los pacientes en los hospitales (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital_survey-spanish.pdf
    June 02, 2025 - Cuestionario sobre la de seguridad de los pacientes en los hospitales SOPSTM Hospital Survey Version: 1.0 Language: Spanish Note • For more information on getting started, selecting a sample, determining data collection methods, establishing data collection procedures, conducting a Web-based survey, and pre…

  14. The Emergency Department & Catheter Insertions | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-slides.html
    December 01, 2017 - The Emergency Department & Catheter Insertions Slide Presentation Slide 1 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 Brigham and Women’s…

  15. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/assess-psc-hsop-facguide.docx
    January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle Slide Title and Commentary Slide Number and Slide Title Slide Assess Patient Safety Culture Using the Hospital Survey on Patient Safety SAY: In this module, we will introduce the Hospital Survey on Patient Safety, or HSOPS, and review why it is important, as wel…

  16. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/build-businesscase-facguide.docx
    January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle Slide Title and Commentary Slide Number and Slide Title Slide Build a Business Case for Quality Improvement SAY: This slide set introduces building a business case for quality improvement. Slide 1 Learning Objectives SAY: After reviewing this slide set, you…

  17. Presentation: Program Overview

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/assess-psc-hsop-slides.pptx
    January 01, 2017 - Presentation: Program Overview Assess Patient Safety Culture Using the Hospital Survey on Patient Safety AHRQ Safety Program for Mechanically Ventilated Patients AHRQ Pub. No. 16(17)-0018-30-EF January 2017 Using HSOPS ‹#› AHRQ Safety Program for Mechanically Ventilated Patients 1 Learning Objectives After t…

  18. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
    January 01, 2022 - Spotlight Spotlight False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy Source and Credits • This presentation is based on the September 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by:…

  19. Around the Block | PSNet

    psnet.ahrq.gov/web-mm/around-block
    March 04, 2020 - Around the Block Citation Text: Minichiello T. Around the Block. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  20. Monitoring for Perinatal Safety: Electronic Fetal Monitoring (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.pdf
    May 01, 2017 - Monitoring for Perinatal Safety: Electronic Fetal Monitoring AHRQ Safety Program for Perinatal Care Monitoring for Perinatal Safety: Electronic Fetal Monitoring AHRQ Publication No. 17-0003-18-EF May 2017 SAY: The Monitoring for Perinatal Safety bundle provides information on the use of electronic fetal mo…
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