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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.257_slideshow.ppt
December 01, 2011 - Spotlight Case July 2008
Spotlight Case
Order Interrupted by Text: Multitasking Mishap
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*
Source and Credits
This presentation is based on the December 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: John Halamka, MD, MS, Chief Informa…
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psnet.ahrq.gov/node/33780/psn-pdf
July 01, 2015 - Safety and Medical Education
January 1, 2014
Ranji SR. Safety and Medical Education. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/safety-and-medical-education
Annual Perspective 2014
As the patient safety field has grown, so too has the appreciation for the need to improve safety in medical
educatio…
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psnet.ahrq.gov/node/49767/psn-pdf
August 21, 2016 - Falling Between the Cracks in the Software
August 21, 2016
Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/falling-between-cracks-software
The Case
A 61-year-old man with a history of osteoarthritis was scheduled for a total knee replacement. Prio…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
May 01, 2013 - Spotlight Case July 2008
Spotlight Case
Right Regimen, Wrong Cancer: Patient Catches Medical Error
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*
Source and Credits
This presentation is based on the May 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Joseph O. Jacobson, MD, MSc…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.143_slideshow.ppt
January 01, 2015 - Spotlight Case [MONTH] 2003
Spotlight Case February 2007
The ‘Customer’ Is Always Right
Source and Credits
This presentation is based on the February 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Niraj L. Sehgal,…
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psnet.ahrq.gov/node/33725/psn-pdf
February 01, 2012 - Balancing Supervision and Autonomy: An Ongoing
Tension
February 1, 2012
Dine JC, Myers JS. Balancing Supervision and Autonomy: An Ongoing Tension. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension
Perspective
Graduate Medical Education (GME) has changed …
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psnet.ahrq.gov/node/49647/psn-pdf
February 01, 2012 - Amended Lab Results: Communication Slip
February 1, 2012
Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
The Case
A 25-year-old woman in her first pregnancy was seen at 33 weeks' gestation with new onset hypertension
an…
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psnet.ahrq.gov/node/33585/psn-pdf
March 15, 2025 - Radiation Safety
March 15, 2025
Radiation Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/radiation-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2025…
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - These include: (i) establishing a no interruption zone (NIZ); (ii) ensuring a do-not-disturb approach
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/implementing-guide.pdf
March 01, 2017 - Leaders can demonstrate this
commitment by ensuring facility staff have the time and resources to achieve … culture goals, assemble the core team, and keep that
team engaged throughout the intervention by—
o Ensuring
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www.ahrq.gov/sites/default/files/2025-03/chaudhry-report.pdf
January 01, 2025 - Final Progress Report: Yale Center for Healthcare Innovation, Redesign, and Learning (CHIRAL)
Final Progress Report
Project Title: Yale Center for Healthcare Innovation, Redesign, and Learning (CHIRAL)
PI: Sarwat I. Chaudhry
Yale University
Inclusive Dates: 9/30/2014-9/29/2019
Agency for Healthcare Research and Qua…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/health-systems-research.pdf
October 01, 2017 - Understanding Health-Systems’ Use of and Need for Evidence To Inform Decisionmaking
White Paper
Understanding Health-Systems’ Use of and
Need for Evidence To Inform Decisionmaking
Research White Paper
Understanding Health-Systems’ Use of and
Need for Evidence To Inform Decisionmaking
Prepared for:
Agency …
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www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/inline-files/2015annlrpt%20(4)_0.pdf
January 01, 2016 - Partners are also a powerful vehicle for ensuring that America’s primary care workforce remains up to
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www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/inline-files/2015annlrpt%20(4).pdf
January 01, 2016 - Partners are also a powerful vehicle for ensuring that America’s primary care workforce remains up to
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-results-search-strategies-developed-with-without-text-mining-tools.pdf
March 01, 2021 - In addition, the peer review process,
while ensuring the searches were of comparable quality, may have
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www.ahrq.gov/sites/default/files/2025-03/singer-benneyan-phillips-report.pdf
January 01, 2025 - complex problems that demand
systems-level approaches and cooperation among multiple disciplines.2–4 Ensuring … high risk based on new problems or exacerbations
of underlying comorbidities, and coordinating and ensuring … They also designed, with input from patients, a new standard
process for ensuring naloxone prescribing
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digital.ahrq.gov/sites/default/files/docs/citation/cds-connect-environmental-scan.pdf
December 01, 2017 - Basing care decisions on these evidence-based
recommendations, while ensuring patient-centered, patient-specific … Tools and resources, as well as CDS, are dedicated
toward ensuring that prescribers understand the MME
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/cervical-cancer-screening
August 21, 2018 - Clinicians should focus on ensuring that women receive adequate screening, appropriate evaluation of … Implementation should therefore focus on ensuring that women receive adequate screening, regardless of
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www.ahrq.gov/sites/default/files/publications/files/ptflowguide.pdf
January 01, 2014 - Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals
Improving Patient Flow
and Reducing Emergency
Department Crowding:
A Guide for Hospitals
Improving Patient Flow
and Reducing Emergency
Department Crowding:
A Guide for Hospitals
Megan McHugh, PhD
Kevin Van Dyke, MPP
Mark Mc…
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hcup-us.ahrq.gov/db/nation/nass/2017_NASS_Introduction.pdf
January 01, 2017 - HEALTHCARE COST AND UTILIZATION PROJECT — HCUP
HEALTHCARE COST AND UTILIZATION PROJECT — HCUP
A FEDERAL-STATE-INDUSTRY PARTNERSHIP IN HEALTH DATA
Sponsored by the Agency for Healthcare Research and Quality
INTRODUCTION TO
THE HCUP NATIONWIDE AMBULATORY SURGERY SAMPLE (NASS)
2017
…