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psnet.ahrq.gov/node/49504/psn-pdf
March 01, 2006 - Liposuction Gone Awry
March 1, 2006
Yates JA. Liposuction Gone Awry. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/liposuction-gone-awry
The Case
A 54-year-old man with HIV was referred to a plastic surgeon for cosmetic surgery. In the plastic surgeon’s
office, he underwent neck and facial liposuction wit…
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psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
October 01, 2013 - New Patient Mistakenly Checked in as Another
Citation Text:
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar B…
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psnet.ahrq.gov/node/49640/psn-pdf
November 01, 2011 - The Case for Patient Flow Management
November 1, 2011
Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/case-patient-flow-management
The Case
A 52-year-old woman with a history of major depression, posttraumatic stress disorder, and alcohol abuse
wa…
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psnet.ahrq.gov/node/49662/psn-pdf
August 01, 2012 - Wrong Turn through Colon: Misplaced PEG
August 1, 2012
Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
The Case
An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…
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psnet.ahrq.gov/node/49809/psn-pdf
October 01, 2017 - Hyperbilirubinemia Refractory to Phototherapy
October 1, 2017
Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
The Case
A 1-day-old full-term infant was noted to have elevated total serum bilirubin (…
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psnet.ahrq.gov/node/33649/psn-pdf
May 01, 2007 - In Conversation with...Sir Liam Donaldson, MD, MSc
May 1, 2007
In Conversation with..Sir Liam Donaldson, MD, MSc. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
Editor's Note: Sir Liam Donaldson, MD, MSc, is England's Chief Medical Officer, a post often referre…
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psnet.ahrq.gov/node/49462/psn-pdf
October 01, 2004 - Thin Air
October 1, 2004
Gaba DM. Thin Air. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/thin-air
Case Objectives
Identify the gas-specific non-interchangeable connectors used for bulk gas supply outlets in
hospitals.
Define forcing function, both in engineered safety devices and in human procedures.
R…
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www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/carecoordination-slides.html
June 01, 2018 - Ensuring that each person and family is engaged as partners in their care. … Slide 16
Complete Written Discharge Instructions
Effective care coordination begins by ensuring
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www.ahrq.gov/sites/default/files/wysiwyg/sops/sops-action-planning-tool.pdf
November 01, 2022 - Other potential barriers could be more basic issues, such as ensuring staff can leave their work area
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
May 05, 2008 - In addition to ensuring continued success, this step also involves
monitoring for new problems created
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/chlamydial-infection-screening-2007
June 15, 2007 - Prevention
Primary care clinicians and the health care systems in which they work are responsible for ensuring
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/mkAgTNR-2jobBcN-2Ysxfb
July 01, 2007 - Prevention
Primary care clinicians and the health care systems in
which they work are responsible for ensuring
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www.ahrq.gov/sites/default/files/2024-01/joseph2-report.pdf
January 01, 2024 - Final Progress Report: Developing and Disseminating a Patient Safety Risk Assessment (PSRA) Toolkit
Final Progress Report
1. TITLE PAGE
Grant Number: 5R13HS021824-03
FAIN: R13HS021824
Principal Investigator: Anjali Joseph
Project Title: Developing and disseminating a Patient Safety Risk Assessment (PSRA) toolkit
…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/cancer-decision-support-tools_research-protocol.pdf
November 12, 2013 - DST_Draft_Protocol_Nov_4_2013_clean (2)
Evidence-based Practice Center Systematic Review Protocol
Project Title: Decision support tools for screening and treatment decisions in early cancer
I.…
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/building-capacity/en-bsc-interim-report-1.pdf
January 31, 2024 - Ohio developed this model in line with its co-design process, ensuring that
participant (health system … And what does that
really look like and ensuring that I communicate that well with our members so that … Over time, HHOI changed its processes to include a “warm handoff” where possible,
ensuring that partners
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Implement_Hndbook_508.pdf
April 30, 2013 - CNAs drafted an open family
presence policy that outlined guidelines for visitors with the goal of ensuring … Ensuring positive physician-patient
communication about hospital quality information (presentation);
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www.ahrq.gov/sites/default/files/2025-02/chen-report.pdf
January 01, 2025 - aspect of primary care,
tracking and following up on laboratory findings and diagnoses as well as ensuring … Fourteen focused on the effectiveness of care, ensuring the delivery of appropriate
evidence-based best
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state3.html
January 01, 2024 - Careful attention to sociotechnical factors, such as ensuring responsibility for closing the loop on … communication strategies. 193 , 200,203 These include strategies for improving the interaction 193,194 and ensuring
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
April 02, 2008 - growing body of evidence indicates that interprofessional team
communication plays a significant role in ensuring … aspect of delivering
patient-centered care,5 while using all resources available to the team38 for ensuring
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs021590-ralston-final-report-2017.pdf
January 01, 2017 - support of a relationship; matching the design of persuasive reminding
to the individual and task; ensuring … support of a relationship; matching the design
of a persuasive reminding to the individual and task; ensuring