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psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely-intensive-care
October 30, 2024 - The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an
Order is Not Enough
April 28, 2021
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
Disclosure of Relev…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/webinar01/sl_fuzzyset.ppt
May 14, 2013 - AHRQ Slide Template 2004
Advanced Methods in Delivery System Research –
Planning, Executing, Analyzing, and
Reporting Research on
Delivery System Improvement
Webinar #1: Fuzzy Set Analysis
Presenter: Marcus Thygeson, MD
Discussant: Jodi Holtrop, PhD,
Moderator: Michael I. Harrison, PhD
Sponsored by AHRQ’s Deliv…
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psnet.ahrq.gov/node/849661/psn-pdf
June 28, 2023 - Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
June 28, 2023
Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During
Anesthesia for Emergency Cesarean Delivery. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/implement/teamworknotes.docx
June 02, 2025 - SAY:
The “Implement Teamwork and Communication” module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit will help you understand the importance of effective communication and transparency, identify barriers to communication, and apply the effective teamwork and communication tools from CUSP and TeamSTEP…
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www.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
September 01, 2013 - Patient and Family Engagement
Facilitator Notes
The Patient and Family Engagement module of the Comprehensive Unit-based Safety Program (CUSP) Toolkit. The CUSP toolkit is a modular approach to patient safety, and modules presented in this toolkit are interconnected and are aimed at improving patient safety. …
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight05.pdf
September 08, 2015 - CHIPRA Quality Demonstration Grant Program Evaluation Highlight No. 5
The CHIPRA Quality
Demonstration Grant Program
In February 2010, the Centers for Medicare &
Medicaid Services (CMS) awarded 10 grants,
funding 18 States, to improve the quality of
health care for children enrolled in Medicaid
and the Children…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight07.pdf
September 08, 2015 - Evaluation Highlight No. 7: How are CHIPRA quality demonstration States designing and implementing caregiver peer support programs?
The CHIPRA Quality
Demonstration Grant Program
In February 2010, the Centers for Medicare &
Medicaid Services (CMS) awarded 10 grants,
funding 18 States, to improve the quality of
h…
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psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
January 01, 2024 - Spotlight
Spotlight
Missed Connection: A Case of Inadequate ECG
Oversight in Cardiac Surgery
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Christian Bohringer, MBBS, …
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psnet.ahrq.gov/node/865429/psn-pdf
April 24, 2024 - Missed Connection: A Case of Inadequate ECG Oversight
in Cardiac Surgery
April 24, 2024
Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac
Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.pdf
May 01, 2017 - Implement Teamwork and Communication for Perinatal Safety
AHRQ Safety Program for Perinatal Care
Implement Teamwork and Communication for Perinatal Safety
AHRQ Publication No. 17-0003-3-EF
May 2017
SAY:
The Implement Teamwork and
Communication module of the AHRQ Safety
Program for Perinatal Care will help yo…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving.pptx
May 01, 2017 - Improving Communication and Teamwork in the Surgical Environment
Improving Communication and Teamwork in the Surgical Environment Module
AHRQ Safety Program for Ambulatory Surgery
AHRQ Pub. No. 16(17)-0019-2-EF
May 2017
Communication and Teamwork | ‹#›
AHRQ Safety Program for Ambulatory Surgery
1
Objectives
…
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psnet.ahrq.gov/node/60268/psn-pdf
April 29, 2020 - Complications of ECMO During Transport
April 29, 2020
Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
The Case
A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with
acute on chro…
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psnet.ahrq.gov/node/33804/psn-pdf
March 03, 2016 - In Conversation With… Paul McGann, MD
March 1, 2016
In Conversation With… Paul McGann, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
Editor's note: Dr. McGann is the Chief Medical Officer for Quality Improvement at the Centers for
Medicare & Medicaid Services (CMS). He…
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www.ahrq.gov/sites/default/files/2024-05/fraser-report.pdf
January 01, 2024 - Final Progress Report: Building the Evidence Base for Vomit Clean-Up Procedures in Long-Term Care Facilities
PROJECT TITLE: Building the Evidence Base for Vomit Clean-Up Procedures in Long-term Care
Facilities
PRINCIPAL INVESTIGATOR AND TEAM MEMBERS:
Angela M. Fraser, Ph.D. (PI)1
Xiuping Jiang, Ph.D.1 (coPI)
Jan…
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www.ahrq.gov/hai/pfp/hacrate2013.html
January 01, 2018 - 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013
Next Page
Table of Contents
2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013
Appendix
References
Summary
…
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Retained Surgical Items: Causation and Prevention
February 26, 2025
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
Background
A retained surgical item (RSI) is a surgical patient safety pro…
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psnet.ahrq.gov/node/836879/psn-pdf
April 27, 2022 - In Conversation With... Michael L. Millenson
April 27, 2022
In Conversation With.. Michael L. Millenson. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-michael-l-millenson
December 16, 2021
Editor’s note: Michael L. Millenson is the President of Health Quality Advisors LLC, author of the c…
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - SPOTLIGHT CASE
Getting to the Root of the Matter
Citation Text:
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Schola…
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digital.ahrq.gov/sites/default/files/docs/lesson/09-0029-ef-cdm.pdf
January 01, 2009 - Innovations in Using Health IT for Chronic Disease Management
Innovations in Using
Health IT for
Chronic Disease Management
Agency for Healthcare Research and Quality
Advancing Excellence in Health Care www.ahrq.gov Health IT
http://www.ahrq.gov/
Innovations in Using
Health IT for
Chronic D…