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psnet.ahrq.gov/node/49712/psn-pdf
June 01, 2014 - May I Have Another?—Medication Error
June 1, 2014
Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
The Case
A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a
pharmacology-tra…
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psnet.ahrq.gov/node/33663/psn-pdf
September 15, 2008 - Implementing a Patient Safety Program at a Large
National Health System
January 1, 2008
Hauck LD, Jacob J. Implementing a Patient Safety Program at a Large National Health System. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
Perspectiv…
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psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-pandemic
October 30, 2024 - A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic
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April 27, 2022
Innovation
Conta…
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psnet.ahrq.gov/node/50392/psn-pdf
September 01, 2019 - In Conversation With… Shantanu Agrawal, MD, MPhil
September 1, 2019
In Conversation With… Shantanu Agrawal, MD, MPhil. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil
Editor's note: Dr. Agrawal is president and CEO of the National Quality Forum (NQF). He is the form…
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psnet.ahrq.gov/node/852808/psn-pdf
August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication
Breakdown.
August 30, 2023
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
Disclosure of Relevant Financial Relationship…
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psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
January 01, 2023 - Spotlight
Spotlight
Prolonged DKA in Pregnancy: A Case of Communication
Breakdown
Source and Credits
• This presentation is based on the August 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarah Marshall, MD and Nina M. …
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digital.ahrq.gov/sites/default/files/docs/page/AppendixB.pdf
February 01, 2012 - B-1
Appendix B: Getting Ready: A Planning Checklist for Rural and Community Hospitals Considering Implementing Health IT
Appendix B: Getting Ready: A Planning Checklist
for Rural and Community Hospitals Considering
Implementing Health IT
Getting Ready: A Planning Checklist for Rural and Community Hospitals
Consid…
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psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
January 03, 2017 - SPOTLIGHT CASE
Treatment Challenges After Discharge
Citation Text:
Coffey C. Treatment Challenges After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
Google Scholar Bib…
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meps.ahrq.gov/data_stats/nhc_acronyms.shtml
December 31, 1996 - NHC acronyms and terms
Skip to main content
An official website of the Department of Health & Human Services
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psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
July 23, 2024 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care
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December 23, 2020
…
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digital.ahrq.gov/program-overview/research-reports/2022-year-review/research-themes-and-findings
January 01, 2022 - Research Themes and Findings
The DHR program funds research that demonstrates how digital healthcare solutions can be designed and implemented to improve healthcare system performance and patient health outcomes. Our funded research focuses on advancing patient safety, care, and shared dec…
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psnet.ahrq.gov/node/861881/psn-pdf
January 31, 2024 - In Conversation with...Richard Ricciardi about Office-
Based Patient Safety
January 31, 2024
Ricciardi R, Lee M, Mossburg S. In Conversation with..Richard Ricciardi about Office-Based Patient Safety.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-pa…
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digital.ahrq.gov/sites/default/files/docs/HealthITandUnderservedPopulations.pdf
September 17, 2010 - National Web-Based Teleconference on Health IT and Underserved Populations: Health IT Adoption in Rural Clinical Settings
National Web-Based Teleconference on Health IT
and Underserved Populations
Health IT Adoption in Rural Clinical Settings
August 27, 2010
Moderator:
Angela Lavanderos
A…
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psnet.ahrq.gov/node/857259/psn-pdf
November 30, 2023 - Medication Mix-Up Leads to Patient Death
November 30, 2023
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
The Case
An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…
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www.ahrq.gov/sites/default/files/2024-12/danforth-report.pdf
January 01, 2024 - Final Progress Report: Electronic Clinical Surveillance To Measure and Improve Safety in Ambulatory Care
Final Progress Report
November 2019
Title
Electronic Clinical Surveillance to Measure and Improve Safety in Ambulatory Care
Principal Investigator and Team Members
Kim N. Danforth,1 Erin E. Hahn,1 Brian S. Mi…
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www.ahrq.gov/action-alliance/resources/type-harm.html
July 01, 2025 - Resources by Safety Topic
Contents Diagnostic Safety Emergency Preparedness Falls Healthcare-Associated Infections Maternal Safety Medication Safety Never Events Opioid Safety Pressure Ulcers Readmissions Sepsis Surgical Safety Transitions in Care Venous Thromboembolism Diagnostic Safety AHRQ Diagnostic Steward…
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psnet.ahrq.gov/node/33637/psn-pdf
August 01, 2006 - In Conversation with...Lucian Leape, MD
August 1, 2006
In Conversation with..Lucian Leape, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: What kind of career did you fashion for yourself prior to
getting involved in safety an…
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www.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
June 01, 2022 - Patient Safety Tools
The Agency for Healthcare Research and Quality (AHRQ) offers tools for health care organizations, providers, policymakers, and patients to improve patient safety in health care settings. The free tools and resources listed here are available online and in print.
Contents
Tools for H…
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www.ahrq.gov/es/patient-safety/settings/hospital/match/chapter-3.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Chapter 3. Developing Change: Designing the Medication Reconciliation Process
Previous Page Next Page
Table of Contents
Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Recon…
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www.ahrq.gov/hai/tools/mvp/modules/vae/overview-off-ventilator-slides.html
February 01, 2017 - Overview: Getting Patients Off the Ventilator Faster: Slide Presentation
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients
Overview: Getting Patients Off the Ventilator Faster
Slide 2: Learning Objectives
After this session, yo…