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psnet.ahrq.gov/node/33635/psn-pdf
July 01, 2006 - In Conversation with...Allan Frankel, MD
July 1, 2006
In Conversation with..Allan Frankel, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about how you became interested in this
kind of work.
Dr. Allan …
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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/node/33754/psn-pdf
September 01, 2013 - In Conversation With… Sidney Dekker, MA, MSc, PhD
September 1, 2013
In Conversation With… Sidney Dekker, MA, MSc, PhD. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd
Editor's note: Sidney Dekker is Professor and Director of the Safety Science Innovation Lab at Grif…
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psnet.ahrq.gov/node/852808/psn-pdf
August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication
Breakdown.
August 30, 2023
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
Disclosure of Relevant Financial Relationship…
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psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
January 01, 2023 - Spotlight
Spotlight
Prolonged DKA in Pregnancy: A Case of Communication
Breakdown
Source and Credits
• This presentation is based on the August 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarah Marshall, MD and Nina M. …
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psnet.ahrq.gov/node/49573/psn-pdf
January 01, 2009 - Dangerous Shift
November 1, 2008
Patterson ES. Dangerous Shift. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/dangerous-shift
Case Objectives
Review the evidence base on erroneous actions related to shift changes.
Understand the limits of standardizing handoffs in preventing errors at shift change.
Expla…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/4es-early-mobility-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
The Four Es of Early Mobility
SAY:
This module explains how to apply the Four Es of the TRIP framework to Early Mobility: engage, educate, execute, and evaluate.
Slide 1
Learning Objectives
SAY:
A…
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psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - Failure to Rescue
Citation Text:
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubM…
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hcup-us.ahrq.gov/datainnovations/BriefIntrotoICD-10Codes041117.pdf
April 11, 2017 - . 6
Example of One ICD-9-PCS Code Mapping to Many Potential ICD-10-CM Codes ................. 9
Examples … They are followed by
examples illustrating some of these differences.
Table 1. … They are followed by
examples illustrating some of these differences.
Table 5. … Examples of Situations in Which a Single ICD-10-PCS Code Describes a Procedure That
Requires ICD-9- … The specific codes in each row are examples of one of the many codes that will map backwards to
the
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effectivehealthcare.ahrq.gov/sites/default/files/study-eligibility-criteria.ppt
January 01, 2000 - Study population size (N > 200)
Study design (randomized controlled trials)
Some Sample Criteria
Examples … Examples of Bias in This Context
Inappropriate eligibilty criteria may limit applicability of the review … Examples of Bias in This Context
For example, the included studies may not have been conducted in the … Exercise 1: PICOTS
Here are examples of further specification of the PICOTS (population, intervention … These are only examples, and the review team should think through as many issues as are relevant to the
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psnet.ahrq.gov/node/34953/psn-pdf
February 03, 2011 - Numerous examples are provided throughout the article.
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psnet.ahrq.gov/node/46357/psn-pdf
May 17, 2018 - This commentary uses case examples
to illustrate how incorrect or incomplete labeling can affect care
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psnet.ahrq.gov/node/37610/psn-pdf
June 16, 2011 - This article presents examples (primarily from outside health
care) to illustrate these concepts and
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psnet.ahrq.gov/node/35312/psn-pdf
January 02, 2017 - Drawing from more than 7200 wrong
administration technique errors, a number of true case examples are
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psnet.ahrq.gov/node/45021/psn-pdf
April 06, 2016 - Staffordshire NHS Foundation Trust inquiry and the Veterans Affairs health system investigation as
examples
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psnet.ahrq.gov/node/74112/psn-pdf
April 14, 2017 - segregation, healthcare quality and access, discriminatory incarceration) and provides
intersectoral examples
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psnet.ahrq.gov/node/46996/psn-pdf
May 23, 2018 - The authors describe their multimodal educational approach and provide examples of fellow-led projects
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psnet.ahrq.gov/node/35802/psn-pdf
January 02, 2017 - The author also provides case examples for
reconciliation errors at admission, transfer of care, and
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psnet.ahrq.gov/node/34803/psn-pdf
January 05, 2017 - Discussion includes a description of the RCA system employed, examples of
events analyzed, and an informative
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psnet.ahrq.gov/node/34812/psn-pdf
March 05, 2008 - Case examples are included to
illustrate the mechanics of the technique, in the context of creating