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psnet.ahrq.gov/node/50927/psn-pdf
February 21, 2020 - Patient Safety in Primary Care
February 21, 2020
Schiff G, Hall KK, Fitall E. Patient Safety in Primary Care. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/patient-safety-primary-care
Introduction
A strong primary care system is foundational to achieving high-quality, accessible, efficient healthcare …
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psnet.ahrq.gov/node/49818/psn-pdf
January 01, 2018 - A Costly Colonoscopy Leads to a Delay in Diagnosis
January 1, 2018
Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
The Case
A 50-year-old man presented to a primary care clinic to establish care, as he ha…
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psnet.ahrq.gov/node/33646/psn-pdf
February 01, 2007 - In Conversation with...Joseph Britto, MD
February 1, 2007
In Conversation with..Joseph Britto, MD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
Editor's Note: Joseph Britto, MD, is CEO and Co-founder of Isabel Healthcare Inc. Isabel, a clinical
decision support syste…
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www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/webinar02/spcslides.html
July 01, 2013 - Advanced Methods in Delivery System Research - Planning, Executing, Analyzing, and Reporting Research on Delivery System Improvement
Webinar #2: Statistical Process Control (Slide Presentation)
This slide presentation was presented on May 14, 2013.
Presenter: Jill Marsteller, PhD, MPP Discussant: Stephen Al…
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psnet.ahrq.gov/node/49484/psn-pdf
June 01, 2005 - Two Pills, Same Drug
June 1, 2005
Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/two-pills-same-drug
The Case
A 34-year-old woman with AIDS developed a fever and hypotension due to suspected pneumonia. Her past
medical history included several AIDS-related complica…
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psnet.ahrq.gov/node/49734/psn-pdf
May 01, 2015 - Departure From Central Line Ritual
May 1, 2015
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/departure-central-line-ritual
The Case
A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alco…
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psnet.ahrq.gov/node/846125/psn-pdf
March 15, 2023 - The I-READI Quality and Safety Framework: Strong
Communications Channels and Effective Practices to
Rapidly Update and Implement Clinical Protocols During a
Time of Crisis
March 15, 2023
https://psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-
and-effective
Summary
…
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psnet.ahrq.gov/node/49523/psn-pdf
November 01, 2006 - Urinary Retention Dilemma
November 1, 2006
Joseph AC. Urinary Retention Dilemma. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/urinary-retention-dilemma
The Case
Following an elective thyroidectomy, a 56-year-old man with a history of benign prostatic hypertrophy
(BPH) and urinary hesitancy returned to th…
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psnet.ahrq.gov/node/33666/psn-pdf
October 01, 2008 - Methicillin-Resistant Staphylococcus aureus
April 1, 2008
Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
Perspective
Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
May 01, 2015 - PowerPoint Presentation
Spotlight
Errors in Sepsis Management
This presentation is based on the May 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: David Shimabukuro, MD, University of California, San Francisco (UCSF)
Editor, AHRQ WebM&M: Rober…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/nashp-webinar-on-quality_measure-use.pdf
September 21, 2015 - Title of Presentation:
Using Quality Measures to Drive
Improvement:
Presentation for the National Academy of State Health
Policy’s Vanguard Network and CHIP Directors
Lessons from the CHIPRA Quality
Demonstration
Cindy Brach, MPP • Grace Anglin, MPH •
Kyra Chamberlain, MS, RN • David Kelley, MD, MPA
Se…
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psnet.ahrq.gov/node/49592/psn-pdf
October 01, 2009 - Danger in Disruption
October 1, 2009
Fontaine DK. Danger in Disruption. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/danger-disruption
The Case
A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had
metabolic alkalosis (pH = 7.58), and her last peripheral…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/physician-staff-engagement-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Physician and Staff Engagement
SAY:
Today, we will give you an overview of physician and staff engagement.
Slide 1
Learning Objectives
SAY:
After this session, you will be able to identify the imp…
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - Spotlight
Too Many Cooks in the Kitchen
Source and Credits
• This presentation is based on the August 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Richard P. Dutton, MD, MBA
o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…
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www.ahrq.gov/hai/tools/mvp/modules/vae/surveillance-fac-guide.html
February 01, 2017 - Ventilator-Associated Event Surveillance: Facilitator Guide
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: Ventilator-Associated Event Surveillance
Say:
This module will focus on ventilator-associated event surveillance and how it can be used in your unit.
Slide 2: Learning Objectiv…
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psnet.ahrq.gov/node/49670/psn-pdf
November 01, 2012 - Missed Pneumonia
November 1, 2012
Rohde JM, Flanders S. Missed Pneumonia. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/missed-pneumonia
The Case
A 32-year-old man presented to the emergency department (ED) with 3 days of fever and right pleuritic
chest pain. Review of systems was negative for cough or dy…
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psnet.ahrq.gov/node/49397/psn-pdf
May 01, 2003 - The Dropped Lung
May 1, 2003
Heffner JR. The Dropped Lung. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dropped-lung
The Case
A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been
hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/sppcii-facilitator-guide.docx
July 01, 2023 - Facilitator Guide for Hospital AIM Team Leads
Facilitator Guide for Hospital AIM Team Leads
What Is This Guide?
This guide is intended as a complement to the online training modules of the Safety Program for Perinatal Care II (SPPC-II) Teamwork Toolkit. It provides helpful information about scheduling and conducting …
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
July 01, 2023 - Patient and Family Engagement for Perinatal Safety: Facilitator Guide
AHRQ Safety Program for Perinatal Care
Slide 1: Patient and Family Engagement for Perinatal Safety
Say:
The Patient and Family Engagement module focuses on an important topic: making sure patients and their family members understand w…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-north-carolina-state-snapshot.pdf
January 01, 2018 - Spotlight on North Carolina -- The National Evaluation of the CHIPRA Quality Demonstration Grant Program
January 2018
This brief highlights the major strategies, lessons learned,
and outcomes from North Carolina’s experience during the
quality demonstration funded by the Centers for Medicare
& Medicaid Services (…