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  1. Medication Handling and Compounding Errors in the Operating Room. | PSNet

    psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
    May 16, 2022 - Medication Handling and Compounding Errors in the Operating Room. Citation Text: Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…

  2. Total Parenteral Nutrition, Multifarious Errors | PSNet

    psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
    January 23, 2017 - SPOTLIGHT CASE Total Parenteral Nutrition, Multifarious Errors Citation Text: Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: …

  3. Comparative Effectiveness of Adjunctive Devices to Remove Thrombi or Protect Against Distal Embolization in Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention of Native Vessels (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/acs-pci-adjunctive-devices_disposition-comments.pdf
    March 01, 2012 - Comparative Effectiveness of Adjunctive Devices to Remove Thrombi or Protect Against Distal Embolization in Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention of Native Vessels Source: http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and- reports/?pageact…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865466/psn-pdf
    March 27, 2024 - Equity in Patient Safety March 27, 2024 Thomas A, Lee M, Mossburg S. Equity in Patient Safety. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/equity-patient-safety Introduction Safety and equity are among the central components that determine quality of care, according to nonprofit advisory agencies l…

  5. Monitoring Fetal Health | PSNet

    psnet.ahrq.gov/web-mm/monitoring-fetal-health
    September 08, 2010 - SPOTLIGHT CASE Monitoring Fetal Health Citation Text: Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNot…

  6. The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department | PSNet

    psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely-intensive-care
    October 30, 2024 - The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …

  7. The SHARE Approach: Facilitator's Guide (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sdm/share-approach/share-facilitator-guide.pdf
    October 01, 2024 - The SHARE Approach: Facilitator's Guide The SHARE Approach: Facilitator’s Guide Overview The SHARE Approach training combines asynchronous video modules and companion in-person group activities. Who should complete the training? Any member of your practice could benefit from the SHARE Approach train…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836892/psn-pdf
    April 07, 2022 - The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department April 7, 2022 https://psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely- intensive-care Summary An increasing volume…

  9. CHIPRA Quality Demonstration Grant Program Evaluation Highlight No. 5 (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight05.pdf
    September 08, 2015 - CHIPRA Quality Demonstration Grant Program Evaluation Highlight No. 5 The CHIPRA Quality Demonstration Grant Program In February 2010, the Centers for Medicare & Medicaid Services (CMS) awarded 10 grants, funding 18 States, to improve the quality of health care for children enrolled in Medicaid and the Children…

  10. Psn-Pdf (pdf file)

    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- …

  11. Evaluation Highlight No. 7: How are CHIPRA quality demonstration States designing and implementing caregiver peer support programs? (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight07.pdf
    September 08, 2015 - Evaluation Highlight No. 7: How are CHIPRA quality demonstration States designing and implementing caregiver peer support programs? The CHIPRA Quality Demonstration Grant Program In February 2010, the Centers for Medicare & Medicaid Services (CMS) awarded 10 grants, funding 18 States, to improve the quality of h…

  12. How are CHIPRA demonstration States approaching practice-level quality measurement and what are they learning? | Agency for Healthcare Research and Quality

    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…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49682/psn-pdf
    April 01, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case April 1, 2013 Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premat…

  14. Psn-Pdf (pdf file)

    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-…

  15. Psn-Pdf (pdf file)

    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…

  16. Too Many Cooks in the Kitchen | PSNet

    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…

  17. Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx Spotlight A Missed Bowel Perforation – the Importance of Diagnostic Reasoning Source and Credits • This presentation is based on the September 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/web…

  18. In Conversation With… Maureen Bisognano | PSNet

    psnet.ahrq.gov/perspective/conversation-maureen-bisognano
    February 26, 2025 - In Conversation With… Maureen Bisognano June 1, 2015  Citation Text: In Conversation With… Maureen Bisognano. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33861/psn-pdf
    July 01, 2018 - In Conversation With… Gordon Schiff, MD July 1, 2018 In Conversation With… Gordon Schiff, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-gordon-schiff-md Editor's note: Dr. Schiff is Associate Director of Brigham and Women's Center for Patient Safety Research and Practice, Associate Pr…

  20. Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx Spotlight Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts  Source and Credits • This presentation is based on the January 2023 AHRQ WebM&M Spotl…
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