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psnet.ahrq.gov/node/49664/psn-pdf
January 01, 2013 - Empty Handoff
September 1, 2012
Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/empty-handoff
The Case
A 29-year-old man with "brittle diabetes" was admitted to the surgery service for incision and drainage of a
leg wound. The patient's medical history included chronic…
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psnet.ahrq.gov/node/49497/psn-pdf
December 01, 2005 - Slippery Slide Into Life
December 1, 2005
Halamek LP. Slippery Slide Into Life. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/slippery-slide-life
The Case
A 25-year-old woman presented to the hospital in labor and at full gestation after receiving uncomplicated
prenatal care. A third-year obstetrics and g…
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psnet.ahrq.gov/node/33672/psn-pdf
September 01, 2008 - In Conversation with…Eric G. Poon, MD, MPH
September 1, 2008
In Conversation with…Eric G. Poon, MD, MPH. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
Editor's note: Eric G. Poon, MD, MPH, is Director of Clinical Informatics at Brigham and Women's
Hospital and Assi…
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psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - Patient Safety Indicators
Citation Text:
Tokareva I, Romano P. Patient Safety Indicators.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Format:
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/engaging-patients-in-treatment
January 01, 2023 - An official website of the Department of Health & Human Services
Search All AHRQ Sites
Careers
Contact Us
Español
FAQs
Email Updates
The Academy
Integrating Behavioral Health & Primary Care
Expand Navi…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/cahps-strategy-6-q.pdf
November 01, 2017 - Strategies for Improving Patient Experience with Ambulatory Care: Standards for Customer Service
The CAHPS Ambulatory Care
Improvement Guide
Practical Strategies for Improving Patient Experience
Section 6: Strategies for Improving Patient Experience with
Ambulatory Care
6.Q. Standards for Customer Service
V…
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www.ahrq.gov/ncepcr/reports/2025-annual-report/healthcare-systems.html
August 01, 2025 - AHRQ’s Investments in Primary Care Research for 2023 and 2024
Healthcare Systems and Infrastructure
Previous Page Next Page
Table of Contents
AHRQ’s Investments in Primary Care Research for 2023 and 2024
Acknowledgements and Authors
Message from the Director of AHRQ’s National Center for Excel…
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www.ahrq.gov/research/publications/ahrq-info-quality-gdlns.html
September 01, 2019 - Guidelines for Ensuring the Quality of Information Disseminated to the Public
C. Agency for Healthcare Research and Quality
Note: Last revised in 2006, these Guidelines also appear on the HHS Web site. AHRQ presents them here with a 2015 Update .
Contents
Agency Mission .
Scope and Applicability …
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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…
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www.ahrq.gov/hai/cauti-tools/archived-webinars/patient-family-engagement-ed-transcript.html
December 01, 2017 - Patient and Family Engagement in the Emergency Department
Webinar Transcript
On the CUSP: Stop CAUTI in the ED
ED Mini-Presentation to Accompany July 7, 2015 ED Coaching Call
Sarah: Hello everyone, and thank you for listening today. My name is Sarah Dalton, and I am a Program Specialist at the Health Res…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/Patient_and_Family_Engagement_in_the_ED_transcript.docx
July 07, 2015 - On the CUSP: Stop CAUTI in the ED
ED Mini-Presentation to Accompany July 7, 2015 ED Coaching Call
Sarah: Hello everyone, and thank you for listening today. My name is Sarah Dalton, and I am a Program Specialist at the Health Research and Educational Trust. Welcome to the fifth mini-presentation in the CAUTI ED cohort …
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psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
November 08, 2013 - Diffusion of Responsibility Leads to Danger
Citation Text:
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/dx-safety-workgroup-meeting-notes-aug2025.pdf
September 01, 2025 - Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare, August 1, 2025
Federal Interagency Workgroup:
Improving Diagnostic Safety and Quality in Healthcare
August 1, 2025, 10 AM–noon
1
Workgroup Goal: Established by Senate Report 115-150. The Senate Committee on
Appropriation…
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www.ahrq.gov/research/findings/final-reports/iomracereport/reldatapre.html
May 01, 2018 - Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement
Reviewers
Previous Page Next Page
Table of Contents
Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement
Summary
Reviewers
1. Introduction
2. Evidence of Disparities amo…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/customer-service/cahps-strategy-6-q.pdf
November 01, 2017 - Strategies for Improving Patient Experience with Ambulatory Care: Standards for Customer Service
The CAHPS Ambulatory Care
Improvement Guide
Practical Strategies for Improving Patient Experience
Section 6: Strategies for Improving Patient Experience with
Ambulatory Care
6.Q. Standards for Customer Service
V…
-
psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery
January 19, 2016 - Bowel Injury After Laparoscopic Surgery
Citation Text:
Moorthy K. Bowel Injury After Laparoscopic Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
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psnet.ahrq.gov/node/49762/psn-pdf
June 01, 2016 - The Case of Mistaken Intubation
June 1, 2016
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/case-mistaken-intubation
Case Objectives
Appreciate that most older adults and many younger chronically ill patients have discussed or
documented their preferences for l…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/simulation-slides.html
July 01, 2023 - Establishing a Program of In Situ Simulations: Slide Presentation
AHRQ Safety Program for Perinatal Care
Slide 1: AHRQ Safety Program for Perinatal Care
Establishing a Program of In Situ Simulations
Slide 2: Learning Objectives
Image: Four ascending steps show the learning objectives:
Describe i…
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www.ahrq.gov/research/findings/final-reports/ssi/ssi4.html
April 01, 2018 - Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection
Chapter 4. Assessing Surgeon Acceptance of Risk Adjustment Models
Previous Page Next Page
Table of Contents
Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection
Executiv…
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs024750-sherwin-final-report-2019.pdf
January 01, 2019 - To make the optimization process more efficient,