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  1. Psn-Pdf (pdf file)

    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-…
  2. Psn-Pdf (pdf file)

    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) …
  3. 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…
  4. 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…
  5. 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…
  6. 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 …
  7. Psn-Pdf (pdf file)

    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…
  8. 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…
  9. 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…
  10. 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…
  11. 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…
  12. Psn-Pdf (pdf file)

    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 …
  13. Psn-Pdf (pdf file)

    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…
  14. 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 …
  15. 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 …
  16. 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, …
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. 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://…
  20. 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…