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psnet.ahrq.gov/node/49522/psn-pdf
November 01, 2006 - Getting a Good Report Card: Unintended Consequences
of the Public Reporting of Hospital Quality
November 1, 2006
Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of
Hospital Quality. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-…
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psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis.
February 1, 2023
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
The Cases
Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
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psnet.ahrq.gov/web-mm/death-pca
January 06, 2017 - Death by PCA
Citation Text:
Hicks RW. Death by PCA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
June 02, 2025 - SAY:
The Patient and Family Engagement module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit focuses on an important topic: Making sure patients and their family members understand what is happening during the patient’s hospital stay, are active participants in the patient’s care, and are prepared for…
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
January 01, 2014 - Patient Safety Organizations: A Summary of 2014 Profiles
Patient Safety Organizations:
A Summary of 2014 Profiles
The safety of patients in health care settings remains
a national priority and an important challenge. The
Patient Safety Organization (PSO) program, which
was authorized by the Patient Safety and Qu…
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www.ahrq.gov/sites/default/files/2024-01/phillips-report.pdf
January 01, 2024 - Final Progress Report: Preventing/Managing C. Diff for Nursing Home Residents, Admissions, and Discharges
FINAL PROGRESS REPORT
Project Title: Preventing/Managing C. Diff for Nursing Home Residents, Admissions,
and Discharges
Principal Investigator: Charles D. Phillips, PhD, MPH, Regents Professor,
Texas A&M …
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psnet.ahrq.gov/node/49506/psn-pdf
March 01, 2006 - The Wet Read
March 1, 2006
Arenson RL. The Wet Read. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/wet-read
Case Objectives
Appreciate the limitations of radiology resident emergency coverage.
Understand the rate of discrepancy between radiology resident preliminary reads and attending
radiologists' fina…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
April 01, 2016 - Say:
This presentation will introduce you to Communication and Optimal Resolution,
or the CANDOR process. Some organizations struggle to improve the way they
and their care teams respond to medical harm. The CANDOR process aims to
change that.
Slide 1
Say:
To get started, let’s watch this video.
Video: Do Less…
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu1.html
October 01, 2014 - Preventing Pressure Ulcers in Hospitals
1. Are we ready for this change?
Previous Page Next Page
Table of Contents
Preventing Pressure Ulcers in Hospitals
Overview
Key Subject Area Index
1. Are we ready for this change?
2. How will we manage change?
3. What are the best practices in pressu…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool11_comm_resource.docx
June 02, 2025 - Tool 11: Community Resource Guide
Tool 11: community resource guide
Purpose
Many hospital readmission reduction teams perceive that no community resources are available, even though community behavioral health and social service providers state they rarely receive referrals from hospitals. The purpose of this commu…
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www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
August 01, 2022 - Grand Rounds Presentation
AHRQ Communication and Optimal Resolution Toolkit
Say:
This presentation will introduce you to Communication and Optimal Resolution, or the CANDOR process. Some organizations struggle to improve the way they and their care teams respond to medical harm. The CANDOR process a…
-
psnet.ahrq.gov/node/49478/psn-pdf
April 01, 2005 - Compare and Contrast
April 1, 2005
Cho KC, Chertow GM. Compare and Contrast. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/compare-and-contrast
Case Objectives
Define contrast nephropathy (CN)
List risk factors for CN
Implement pharmacologic strategies for CN prophylaxis
Follow an algorithm for CN risk …
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psnet.ahrq.gov/node/61082/psn-pdf
July 23, 2020 - Long-Term Care and the Response to COVID-19
October 28, 2020
Popejoy LL, Crecelius CA, Fitall E, et al. Long-Term Care and the Response to COVID-19. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/long-term-care-and-response-covid-19
The COVID-19 pandemic has had far-reaching consequences on how the hea…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/overview-ptsoffventilator-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Overview: Getting Patients Off the Ventilator Faster
SAY:
In this module, we will introduce strategies and interventions, as well as adaptive and technical measures, which, when implemented, can help …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/overview-ptsoffventilator-slides.pptx
January 01, 2017 - Presentation: Program Overview
Overview:
Getting Patients Off the Ventilator Faster
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-25-EF
January 2017
Overview ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
1
Learning Objectives
After this session, you will be …
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www.ahrq.gov/hai/tools/mvp/modules/vae/overview-off-ventilator-fac-guide.html
February 01, 2017 - Overview: Getting Patients Off the Ventilator Faster: Facilitator Guide
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: Overview: Getting Patients Off the Ventilator Faster
Say:
In this module, we will introduce strategies and interventions, as well as adaptive and technical measures, …
-
psnet.ahrq.gov/node/863308/psn-pdf
February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in
Death During Endoscopy
February 28, 2024
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
The Case
A…
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psnet.ahrq.gov/node/837660/psn-pdf
July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse
Outcomes
July 8, 2022
Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
The Cases
Case 1: A 64-year-old man came in for a routine bron…
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx
Spotlight
Respiratory Distress after Neck Surgery: Two
Cases of Post-Operative Cervical Hematoma
Source and Credits
• This presentation is based on the January 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://…
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www.ahrq.gov/sites/default/files/2024-01/hall2-report.pdf
January 01, 2024 - Final Progress Report: Safety Advancement in the Emergency Department
FINAL PROGRESS REPORT
PROJECT TITLE: SAFETY ADVANCEMENT IN THE EMERGENCY DEPARTMENT*
PRINCIPAL INVESTIGATOR: KENDALL K. HALL, MD, MS (AHRQ, formerly of UNIV of MARYLAND)
KEY PERSONNEL: YAN XIAO, PhD (BAYLOR, formerly of UNIV of MARYLAND)
ANTHO…