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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 …
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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…
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psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
July 31, 2023 - Procedure Complications – Who is Responsible for Follow up?
Citation Text:
Chalupsky M, Wei H, Marquet E. Procedure Complications – Who is Responsible for Follow up?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Cita…
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psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - The Consequences of Miscommunication Regarding a
Possible Artifact
June 30, 2021
Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
Disclosure of Relevant Financial Relationships…
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
1
Source and Credits
This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Elizabeth Gould, NP-C, COR…
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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…
-
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…
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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…
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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…
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psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
March 19, 2019 - Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.
Citation Text:
Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
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cds.ahrq.gov/sites/default/files/AHRQ_Final_Report_2022.pdf
January 01, 2022 - CDS Connect - Maintenance and Update Final Report (Year 6)
CDS Connect
Maintenance and Update
FINAL REPORT
(Year 6 of CDS Connect)
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
www.ahrq.gov
Contract No. 75FCMC18D0047
Prepared by:
CMS Alliance to Modernize Healthcare …
-
digital.ahrq.gov/sites/default/files/docs/citation/cds-connect-year6-final-report-2022.pdf
January 01, 2022 - CDS Connect - Maintenance and Update Final Report (Year 6)
CDS Connect
Maintenance and Update
FINAL REPORT
(Year 6 of CDS Connect)
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
www.ahrq.gov
Contract No. 75FCMC18D0047
Prepared by:
CMS Alliance to Modernize Healthcare …
-
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/video/module-2-team-leadership-facilitator-guide.pdf
June 02, 2025 - 24
Ensuring
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Tool_6_Pres_TX_508.pptx
July 23, 2010 - for our conversation, I’d like to talk about the importance of patients and families as partners in ensuring
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module5/mod5-facguide.html
March 01, 2017 - every opportunity to engage the resident and family members by providing timely, accurate information, ensuring
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www.ahrq.gov/hai/cusp/modules/implement/teamwork-notes.html
December 01, 2012 - responsibility are transferred from one team member to the next, making the handoff a crucial component of ensuring
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psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
August 01, 2010 - Leaders will need to establish a fertile environment for such individuals by ensuring that PS/QI efforts
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs024062-mazur-final-report-2017.pdf
January 01, 2017 - Overall, these results suggest that challenges exist in ensuring appropriate follow-up of abnormal test … suggest that longitudinal monitoring and tracking of abnormal test results and
patient status can help ensuring … functionality and usability features for ensuring
-
digital.ahrq.gov/sites/default/files/docs/citation/cedar-year1-final-report.pdf
September 01, 2022 - An iterative development
process, where feedback was integrated early and often, was critical to ensuring
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www.ahrq.gov/sites/default/files/wysiwyg/mcc/pccp4p/pccp4p-learningcollab.pdf
September 01, 2025 - Person-Centered Care Planning for Persons With Multiple Chronic Conditions: Learning Collaborative Report
Person-Centered Care Planning for
Persons With Multiple Chronic
Conditions
Learning Collaborative Report
Executive Summary
Background and Objectives
Person-centered care planning (PCCP) is “a process…