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  1. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …
  2. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
  3. 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…
  4. 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…
  5. Psn-Pdf (pdf file)

    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-…
  6. 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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

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

    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…
  13. 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…
  14. Psn-Pdf (pdf file)

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

    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. …
  17. 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…
  18. Psn-Pdf (pdf file)

    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…
  19. 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://…
  20. Psn-Pdf (pdf file)

    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…