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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - Continuity Errors in Resident Clinic
Citation Text:
Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/production-pressures
November 16, 2022 - Production Pressures
Citation Text:
Carayon P. Production Pressures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL Dec Spotlight_Code Status vs Care Status.pptx
Spotlight
Code Status vs. Care Status
Source and Credits
• This presentation is based on the December 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: Rebe…
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www.ahrq.gov/sites/default/files/2024-09/fowler-report.pdf
January 01, 2024 - Final Progress Report: Determining a Learning Curve for Complex Laparoscopic Gastrointestinal Surgery
Title Page
Final Progress Report
Determining a Learning Curve for Complex Laparoscopic
Gastrointestinal Surgery
Principal Investigator: Dennis L. Fowler, MD, MPH
Co-Investigator: R. Todd Ogden, PhD
Co-Investigato…
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psnet.ahrq.gov/node/854897/psn-pdf
October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical
Record Causing an Accidental Medication Overdose
October 31, 2023
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an
Accidental Medication Overdose. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/weight-and-…
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www.ahrq.gov/sites/default/files/2024-11/ballard-report.pdf
January 01, 2024 - Final Progress Report: Using Performance Measurement To Improve the Quality and Safety of Healthcare
Element 1. Title Page:
Using Performance Measurement to Improve
the Quality and Safety of Healthcare
Report on The International Society for Quality in Health Care (ISQua) 6th International
Summit on Indic…
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psnet.ahrq.gov/node/865656/psn-pdf
April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous
Combination
April 24, 2024
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous
Combination. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
The Case
A 26-ye…
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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/73456/psn-pdf
June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult
Intubation and Severe Hypoxemia
June 30, 2021
Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…
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www.ahrq.gov/practiceimprovement/delivery-initiative/rodriguez/index.html
December 01, 2020 - Implementing Team Approaches for Improving Diabetes Care in Health Centers
Slide Presentation by Hector P. Rodriguez
Text version of a slide presentation made by Hector P. Rodriguez, PhD, MPH.
Sign up: Quality Measure Tools Email updates
Slide 1
Implementing Team Approaches for Improving Diabetes Ca…
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/perinatal-care-experience-slides.pdf
March 06, 2025 - Factors that Impact Perinatal Care Experience and Outcomes: Slide Presentation
National Center for Excellence in Primary Care Research
Presents
Factors that Impact Perinatal Care Experience and Outcomes
March 6, 2025
Presented by:
Amy G. Cantor MD, MPH, FAAFP
Lindsay Kennedy Admon, MD, MSc
Mark Allen Clapp, …
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module8/module8-organizational-learning-sustainability.pptx
August 20, 2015 - An Overview of the CANDOR Process
Communication and Optimal Resolution
(CANDOR)
Toolkit
Module 8: Organizational Learning and Sustainability
Module 8, the last module in the CANDOR Toolkit, provides an overview of organizational learning and how an organization can develop a sustainability plan to assure the CAND…
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psnet.ahrq.gov/node/33814/psn-pdf
September 01, 2016 - In Conversation With… Reed V. Tuckson, MD
September 1, 2016
In Conversation With… Reed V. Tuckson, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-reed-v-tuckson-md
Editor's note: Dr. Tuckson is Managing Director of Tuckson Health Connections, LLC, and President of
the American Telemed…
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www.ahrq.gov/sites/default/files/2025-03/smith2-report.pdf
January 01, 2025 - Final Progress Report: A Study of Narrative as the Cognitive Process Underlying Diagnostic Reasoning
A Study of Narrative as the Cognitive Process Underlying Diagnostic Reasoning
PI: Curtis Scott Smith, MD
Team: Chris Francovich, EdD
Magdalena Morris, RN, MSN
Andrew Turner, PhD
Bruce Robbins, PhD
Lynne Robins, …
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psnet.ahrq.gov/node/49528/psn-pdf
January 01, 2015 - The "Customer" Is Always Right
February 1, 2007
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/customer-always-right
Case Objectives
Understand the importance of identifying a patient's agenda.
Appreciate the factors that contribute to unmet patient expectations.
…
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-3-implementation-guide.pdf
June 02, 2025 - 1
Implementation Guide - Module 3
Understanding your Workflow Processes to Prepare for Systems Change
Module Purpose
This module continues the discussion of the steps necessary for systems change to support the
implementation of automatic referral with effective care coordination. Topics include the “w…
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psnet.ahrq.gov/node/49480/psn-pdf
May 01, 2005 - Diagnosing Diagnostic Mistakes
May 1, 2005
McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
Learning Objectives
Understand the biases that may contribute to overcalling medical errors
Describe the impact of conside…
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psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx
Spotlight
Challenging Case of Multiple Suicide Attempts in a
Complex Patient with Psychiatric Comorbidities
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://…
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psnet.ahrq.gov/node/33805/psn-pdf
April 01, 2016 - In Conversation With… Thomas J. Nasca, MD, MACP
April 1, 2016
In Conversation With… Thomas J. Nasca, MD, MACP. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
Editor's note: Dr. Nasca is Chief Executive Officer of the Accreditation Council for Graduate Medical
Educat…