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psnet.ahrq.gov/node/49598/psn-pdf
February 01, 2010 - Medication Reconciliation Pitfalls
February 1, 2010
Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
The Case
A 90-year-old woman who lived alone suffered a mechanical fall with subsequent hip fracture and was
brought to the eme…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/webinar03/logic_models.pptx
July 15, 2013 - Advanced Methods in Delivery System Research – Planning, Executing, Analyzing, and Reporting Research on Delivery System Improvement Webinar #1: Fuzzy Set Analysis
Advanced Methods in Delivery System Research –
Planning, Executing, Analyzing, and
Reporting Research on
Delivery System Improvement
Webinar #3: …
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www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/webinar03/logicmodelsl.html
July 01, 2013 - Advanced Methods in Delivery System Research - Planning, Executing, Analyzing, and Reporting Research on Delivery System Improvement
Webinar #3: Logic Models (Slide Presentation)
This slide presentation was presented at a webinar on June 4, 2013.
Presenter: Dana Petersen, PhD Discussant: Todd Gilmer, PhD Mo…
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psnet.ahrq.gov/node/49467/psn-pdf
December 01, 2004 - A "Weak" Response
December 1, 2004
Reisman AB. A "Weak" Response. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/weak-response
The Case
A primary care physician on call for his group received a call at 9:00PM from a 68-year-old man. He said,
"They started me on a new pill for my blood pressure and now I fe…
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu6.html
October 01, 2014 - Preventing Pressure Ulcers in Hospitals
6. How do we sustain the redesigned prevention practices?
Previous Page Next Page
Table of Contents
Preventing Pressure Ulcers in Hospitals
Overview
Key Subject Area Index
1. Are we ready for this change?
2. How will we manage change?
3. What are the…
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psnet.ahrq.gov/node/49716/psn-pdf
August 21, 2014 - Benefits vs. Risks of Intraosseous Vascular Access
August 21, 2014
Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
The Case
A 72-year-old woman with a history of asthma, congestive heart…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/overview-cuspmvp-slides.pptx
January 01, 2017 - CMV_27_M3_CUSP_SSA_Premortem
Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-27-EF
January 2017
Overview of CUSP for MVP ‹#›
AHRQ Safety Program for Mechanically Ventilat…
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psnet.ahrq.gov/node/49578/psn-pdf
January 01, 2009 - Hospital Admission Due to High-Dose Methotrexate Drug
Interaction
January 1, 2009
Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet
[internet]. 2009.
https://psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
The Case
A 40-year-old wo…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module6/mod6-slides.html
March 01, 2017 - Module 6: Sustainability
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Slide 1: Module 6: Sustainability
Slide 2: Objectives
Define sustainability and understand the importance of maintaining positive change.
Describe the link between sustainability and spread.
Develop a plan for sustainabi…
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psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - X-ray Flip
February 1, 2004
Shapiro MJ. X-ray Flip. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/x-ray-flip
The Case
A 19-year-old man presented to the emergency department with respiratory distress after blunt chest
trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-georgia-state-snapshot.pdf
January 01, 2018 - Spotlight on Georgia -- National Evaluation of the CHIPRA Quality Demonstration Grant Program
This brief highlights the major strategies, lessons learned,
and outcomes from Georgia’s experience from February
2010 to February 2016 with the quality demonstration
funded by the Centers for Medicare & Medicaid
Service…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-oregon-state-snapshot.pdf
January 01, 2018 - Spotlight on Oregon -- The National Evaluation of the CHIPRA Quality Demonstration Grant Program
January 2018
This brief highlights the major strategies, lessons learned,
and outcomes from Oregon’s experience during the quality
demonstration funded by the Centers for Medicare &
Medicaid Services (CMS) through the…
-
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-south-carolina-state-snapshot.pdf
January 01, 2018 - Spotlight on South Carolina -- The National Evaluation of the CHIPRA Quality Demonstration Grant Program
January 2018
This brief highlights the major strategies, lessons learned,
and outcomes from South Carolina’s experience during the
quality demonstration funded by the Centers for Medicare
& Medicaid Services (…
-
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-west-virginia-state-snapshot.pdf
January 01, 2018 - Spotlight on West Virginia -- The National Evaluation of the CHIPRA Quality Demonstration Grant Program
January 2018
This brief highlights the major strategies, lessons learned,
and outcomes from West Virginia’s experience during the
quality demonstration funded by the Centers for Medicare
& Medicaid Services (CM…
-
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-alaska-state-snapshot.pdf
January 01, 2018 - Spotlight on Alaska -- The National Evaluation of the CHIPRA Quality Demonstration Grant Program
January 2018
This brief highlights the major strategies, lessons learned,
and outcomes from Alaska’s experience in the quality
demonstration funded by the Centers for Medicare &
Medicaid Services (CMS) through the Chi…
-
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-idaho-state-snapshot.pdf
January 01, 2018 - Spotlight on Idaho -- The National Evaluation of the CHIPRA Quality Demonstration Grant Program
January 2018
This brief highlights the major strategies, lessons learned,
and outcomes from Idaho’s experience during the quality
demonstration funded by the Centers for Medicare
& Medicaid Services (CMS) through the C…
-
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/nm-statesum.pdf
July 01, 2015 - CHIPRA - Spotlight on New Mexico
July 2015
This brief highlights the major strategies, lessons learned,
and outcomes from New Mexico’s experience in the quality
demonstration funded by the Centers for Medicare &
Medicaid Services (CMS) through the Children’s Health
Insurance Program Reauthorization Act of 2009 (…
-
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-pennsylvania-state-snapshot.pdf
January 01, 2018 - Spotlight on Pennsylvania -- The National Evaluation of the CHIPRA Quality Demonstration Grant Program
This brief highlights the major strategies, lessons learned, and
outcomes from Pennsylvania’s experience from February 2010
to February 2016 with the quality demonstration funded by
the Centers for Medicare & Med…
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load4.html
May 01, 2024 - Cognitive Load Theory and Its Impact on Diagnostic Accuracy
Measures of Cognitive Load
Previous Page Next Page
Table of Contents
Cognitive Load Theory and Its Impact on Diagnostic Accuracy
Introduction to Diagnostic Errors
Fundamental Concepts for Understanding Cognitive Load
Interplay Between…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/kit.html
June 01, 2017 - A Frontline Management System To Sustain Improvement in Safety Practices
Contents
1. Why a Frontline Management System?
2. Components of the Frontline Management System
3. Interactions of Components
4. Using the Model for Improvement
5. Additional Resources
1. Why a Frontline Management System?
M…