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psnet.ahrq.gov/node/33767/psn-pdf
May 01, 2014 - Innovations in Promoting Hand Hygiene Compliance
May 1, 2014
Marra AR, Edmond MB. Innovations in Promoting Hand Hygiene Compliance. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
Perspective
One hundred sixty-five years after the publication of Ignaz Semmel…
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psnet.ahrq.gov/web-mm/thin-air
March 01, 2006 - SPOTLIGHT CASE
Thin Air
Citation Text:
Gaba DM. Thin Air. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/node/49639/psn-pdf
November 01, 2011 - Near Miss with Bedside Medications
November 1, 2011
Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications
Case Objectives
Understanding the definition of near miss—also known as close call.
Appreciate the importance of close calls in reducin…
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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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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - Open wider: Failure to use an interpreter results in
fractured teeth and hypoxia during a simple elective
operation.
December 14, 2022
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia
during a simple elective operation. PSNet [internet]. 2022.
https://psnet.ah…
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psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
March 01, 2006 - Hyperbilirubinemia Refractory to Phototherapy
Citation Text:
Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar …
-
psnet.ahrq.gov/node/49645/psn-pdf
February 01, 2012 - E-prescribing: E for error?
February 1, 2012
Ashton EW. E-prescribing: E for error? PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/e-prescribing-e-error
Case Objectives
Define e-prescribing.
Describe ways in which e-prescribing can reduce health care costs.
State how commonly prescription errors occur wit…
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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/49779/psn-pdf
January 01, 2017 - The Empty Bag
December 1, 2016
Vincent C. The Empty Bag. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/empty-bag
The Case
A 90-year-old woman with end-stage dementia was admitted to an acute care hospital for treatment of a
hip fracture after a fall at a nursing home. During the hospitalization, her kidne…
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psnet.ahrq.gov/node/49508/psn-pdf
January 01, 2007 - Language Barrier
April 1, 2006
Flores G. Language Barrier. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/language-barrier
The Case
A previously healthy 10-month-old girl was taken to a pediatrician's office by her monolingual Spanish-
speaking parents when they noted that their daughter had generalized we…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.281_slideshow.ppt
October 01, 2012 - Spotlight Case July 2008
Spotlight Case
CA-MRSA Skin Infections:
An Ounce of Prevention is Worth a Pound of Cure
*
*
Source and Credits
This presentation is based on the October 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Catherine L…
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www.ahrq.gov/sites/default/files/2024-01/fairbanks-report.pdf
January 01, 2024 - setting results in safer and more
effective medication use.1 These pharmacists are typically involved in ensuring … This was done to minimize bias by ensuring that the chart reviewers remained blinded to the assigned … This was done to minimize bias by ensuring the chart reviewers remained blinded to the assigned intervention
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www.ahrq.gov/sites/default/files/publications/files/psml-planning-grants-final-report.pdf
May 01, 2016 - reducing preventable injuries, (2) fostering better
communication between doctors and patients, (3) ensuring … reducing preventable injuries, (2) fostering better
communication between doctors and patients, (3) ensuring
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
May 01, 2016 - reducing preventable injuries, (2) fostering better
communication between doctors and patients, (3) ensuring … reducing preventable injuries, (2) fostering better
communication between doctors and patients, (3) ensuring
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effectivehealthcare.ahrq.gov/sites/default/files/grading.ppt
January 01, 2013 - The third step is to develop an explicit procedure for ensuring a high degree of interrater reliability
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www.ahrq.gov/sites/default/files/2024-10/barnes-report.pdf
January 01, 2024 - Conclusions
A population health approach to ensuring medication safety through pharmacist use of a DOAC … population-level benefits, implementation teams need to carefully address
pharmacist authority and autonomy while ensuring
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medoffice-resourcelist.pdf
April 01, 2023 - Feedback to frontline staff is a critical component of demonstrating a commitment to safety
and ensuring … creating leadership and clinician buy-in for information exchange, addressing technical issues,
and ensuring
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hcup-us.ahrq.gov/reports/projections/2012-02.pdf
January 01, 2012 - Microsoft Word - hcup_proj_2012-02.docx
Contact Information:
Healthcare Cost and Utilization Project (HCUP)
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
http://www.hcup-us.ahrq.gov
For Technical Assistance with HCUP Products:
Email: hcup@ahrq.gov
or
Phone…
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effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-participant-generated-registries-guide-3rd-ed-addendum-white-paper.pdf
February 01, 2018 - patients while allowing participants to retain a sense of control over their health
information and ensuring … platform designed
to further development of PGRs that has arisen in large part out of concerns for ensuring … Ensuring the safe use of
genomic medicine in children.
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cds.ahrq.gov/sites/default/files/cds/artifact/171/Occupational%20Factors%20which%20Impact%20Diabetes,%20%20A%20Final%20Knowledge%20Resource%20Report%20(2015).pdf
January 01, 2015 - Using Electronic Health Records and Clinical Decision Support to Provide Guidance on
Occupational Factors which Impact Diabetes: A Final Knowledge Resource Report
Revised and resubmitted December 4, 2015
The Diabetes subject matter expert (SME) group
Convened by the Association of Occupational and Environmenta…