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4641. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854848/psn-pdf
      October 31, 2023 - Delay in Malignancy Diagnosis Reflects Systemic Failures October 31, 2023 Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures The Case A 32-year-old man presented to the hospital with…

4642. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60857/psn-pdf
      August 26, 2020 - Nothing Called Small Surgery August 26, 2020 Manske C. Nothing Called Small Surgery. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/nothing-called-small-surgery The Case  A 56-year-old female presented to surgical clinic with pain and swelling in left great toe associated with progressive deformity of the …

4643. Learning From Defects Through Sensemaking: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
      December 01, 2017 - Learning From Defects Through Sensemaking: Slide Presentation AHRQ Safety Program for Surgery Slide 1: AHRQ Safety Program for Surgery—Implementation Learning From Defects through Sensemaking Slide 2: Learning Objectives Describe difference between first-order and second-order problem-solving. L…

4644. Labor and Delivery Unit Safety: Obstetric Hemorrhage | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-obhemorrhage.html
      July 01, 2023 - Labor and Delivery Unit Safety: Obstetric Hemorrhage AHRQ Safety Program for Perinatal Care Purpose of the tool: This tool describes the key perinatal safety elements related to the management obstetric hemorrhage. The key elements are presented within the framework of the Comprehensive Unit-base…

4645. Learn About the Comprehensive Unit-Based Safety Program for Perinatal Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-about-cusp-facilitator-guide.pdf
      May 01, 2017 - Learn About the Comprehensive Unit-Based Safety Program for Perinatal Safety AHRQ Safety Program for Perinatal Care Learn About the Comprehensive Unit-Based Safety Program for Perinatal Safety AHRQ Publication No. 17-0003-1-EF May 2017 SAY: This module introduces the comprehensive unit-based safety program, …

4646. Rapid Response for Perinatal Safety: Rapid Response Systems | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/rapid-response/tool-rapid-response-systems.html
      July 01, 2023 - Rapid Response for Perinatal Safety: Rapid Response Systems AHRQ Safety Program for Perinatal Care Purpose of the tool: This tool describes the key perinatal safety elements that support rapid response systems. The key safety elements are presented within the framework of the Comprehensive Unit-b…

4647. 4. Observations About the Evaluation | Agency for Healthcare Research and Quality
      www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/final-report/section4.html
      October 01, 2015 - National Evaluation of the CHIPRA Quality Demonstration Grant Program: Final Project Report 4. Observations About the Evaluation Previous Page Next Page Table of Contents National Evaluation of the CHIPRA Quality Demonstration Grant Program: Final Project Report 1. Overview 2. Synthesis of Key F…

4648. Summary and Discussion | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily4.html
      July 01, 2018 - Guide to Patient and Family Engagement Summary and Discussion Previous Page Next Page Table of Contents Guide to Patient and Family Engagement Executive Summary Introduction Methods Findings Implications for the Guide Summary and Discussion Next Steps References Appendix A: Draft K…

4649. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49606/psn-pdf
      August 01, 2010 - Weighing In on Surgical Safety August 1, 2010 Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/weighing-surgical-safety Case Objectives Identify the comorbidites associated with obesity that place patients at higher risk for surgical complications. Un…

4650. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73302/psn-pdf
      May 26, 2021 - In Conversation With... Chris Cebollero, BS, CCEMT-P May 26, 2021 In Conversation With.. Chris Cebollero, BS, CCEMT-P. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/conversation-chris-cebollero-bs-ccemt-p Editor’s Note: Chris Cebollero, BS, CCEMT-P, is the President and CEO of Cebollero & Associates C…

4651. Failure to Rescue the Mother | PSNet
      psnet.ahrq.gov/web-mm/failure-rescue-mother
      September 23, 2020 - Failure to Rescue the Mother Citation Text: Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote…

4652. Final Progress Report: Rapid Understanding of Best Practices in Rural Intensive Care (RUBRIC) (pdf file)
      www.ahrq.gov/sites/default/files/2024-05/valley-report.pdf
      January 01, 2024 - Final Progress Report: Rapid Understanding of Best Practices in Rural Intensive Care (RUBRIC) AHRQ GRANT FINAL PROGRESS REPORT TEMPLATE Title Page Title of Project: Rapid Understanding of Best Practices in Rural Intensive Care (RUBRIC) Principal Investigator and Team Members: - Principal Investigator: Thomas S. Va…

4653. Psn-Pdf (pdf file)
      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…

4654. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49573/psn-pdf
      January 01, 2009 - Dangerous Shift November 1, 2008 Patterson ES. Dangerous Shift. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dangerous-shift Case Objectives Review the evidence base on erroneous actions related to shift changes. Understand the limits of standardizing handoffs in preventing errors at shift change. Expla…

4655. Medication Mix-Up Leads to Patient Death | PSNet
      psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
      July 08, 2022 - Medication Mix-Up Leads to Patient Death Citation Text: Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX En…

4656. Making Patient Apps Interoperable With the Health IT Ecosystem (pdf file)
      cdsic.ahrq.gov/sites/default/files/2025-06/SRF%20Topic%20Highlight%20Patient%20App%20Interoperability.pdf
      January 01, 2025 - Making Patient Apps Interoperable With the Health IT Ecosystem AHRQ Pub. No. 25-0053 June 2025 Making Patient Apps Interoperable With the Health IT Ecosystem This resource for app developers explains considerations for developing patient-facing applications (apps) that are interoperable with …

4657. Strategy 6K: Cultivating Cultural Competence | Agency for Healthcare Research and Quality
      www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/communication/strategy6kculturalcompetence.html
      March 01, 2020 - Strategy 6K: Cultivating Cultural Competence Contents 6.K.1. The Problem 6.K.2. Interventions    6.K.2.a. Maintaining Complete and Accurate Information on Enrollees    6.K.2.b. Building a Provider Network to Meet the Community’s Linguistic and Cultural Needs    6.K.2.c. Training Providers on Cultural…

4658. The Consequences of Miscommunication Regarding a Possible Artifact | PSNet
      psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
      May 11, 2019 - SPOTLIGHT CASE The Consequences of Miscommunication Regarding a Possible Artifact Citation Text: Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…

4659. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863650/psn-pdf
      February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance Measurement Tracking, and Performance Feedback February 28, 2024 https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking- and-performance Summary To improve patient care and outcomes in the intensive care unit (ICU…

4660. I. Introduction | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/hotline/intro1.html
      May 01, 2016 - Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events I. Introduction Previous Page Next Page Table of Contents Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events Pr…