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psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-facha
June 30, 2021 - In healthcare design, sometimes we can fall into a routine that we think we know the answer, but we have … patient getting up to go to the bathroom without calling a nurse and putting themselves at risk for a fall
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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - devices], and to be provided instructions for their follow-up care, and then we see that they can't fall … - July 27, 2023
‘I felt like I was dying’: how women with postpartum depression fall
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psnet.ahrq.gov/perspective/covid-19-and-built-environment
June 30, 2021 - In healthcare design, sometimes we can fall into a routine that we think we know the answer, but we have … patient getting up to go to the bathroom without calling a nurse and putting themselves at risk for a fall
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Nemeth_116.pdf
April 27, 2008 - all but life-threatening illness is an example of what
some practitioners have described as a “free fall … recognize and anticipate the trend and reorganize
7
described this situation as a feeling of “free fall
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR
Citation Text:
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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…
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digital.ahrq.gov/sites/default/files/docs/page/Grannis.ppt
January 01, 2004 - Slide 1
Patient Matching in the Indiana Network for Patient Care
Shaun Grannis, M.D. M.S.
The Regenstrief Institute and
Indiana University School of Medicine
Regenstrief Beginnings
Endowed by Sam Regenstrief - inventor of the low cost dishwasher
Obsessed with process improvement
Supported the creation of the…
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs021733-sheehan-final-report-2014.pdf
January 01, 2014 - Patient Self Monitoring to Transfer Physical Therapy Exercise from Clinic to Home - Final Report
Exploratory and Developmental Grant to Improve Health Care Quality through Health Information Technology (IT) (R21)
Project Title: Patient Self Monitoring to Transfer Physical Therapy Exercise from
Clinic t…
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hcup-us.ahrq.gov/datainnovations/clinicaldata/TemplatesforusingHL7v2.jsp
December 02, 2007 - Templates for using HL7 v2.5 messages
An official website of the Department of Health & Human Services
Search All AHRQ Websites
Careers
Contact Us
Espanol
FAQs
Email Updates…
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psnet.ahrq.gov/node/865698/psn-pdf
April 24, 2024 - Patient Safety Amid Nursing Workforce Challenges
April 24, 2024
Leary KB, Lee M, Mossburg S. Patient Safety Amid Nursing Workforce Challenges . PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
Introduction
Nurses are essential to patient care, and having a…
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psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
June 01, 2014 - Mixup Beyond the Medication Label
Citation Text:
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/33856/psn-pdf
April 01, 2018 - Patient Safety During Hospital Discharge
April 1, 2018
Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
Perspective
Patients are admitted to the hospital in the United States 35 million times per year.(1)…
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - The Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
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effectivehealthcare.ahrq.gov/sites/default/files/schwitzer_eccs2012.pdf
July 23, 2012 - Schwitzer_ECCS2012
Slide 1: Addressing
Tensions
When Popular Media and Evidence-‐Based Care
Collide
Gary
Schwitzer
Publisher,
HealthNewsReview.org
Slide 2: Infoxication
We are drowning people who are thirsty for just a sip of balanced infor…
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psnet.ahrq.gov/web-mm/getting-right-doctor-right-away
July 01, 2011 - Getting the (Right) Doctor, Right Away
Citation Text:
Gupta K, Khanna R. Getting the (Right) Doctor, Right Away. 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/picture-speaks-1000-words
July 16, 2015 - A Picture Speaks 1000 Words
Citation Text:
Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.161_slideshow.ppt
October 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case October 2007
Do Not Disturb!
Source and Credits
This presentation is based on the October 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: F. Daniel Duffy, MD, University of Oklahoma, and…
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psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx
Spotlight
When the Indications for Drug
Administration Blur
Source and Credits
• This presentation is based on the June 2020 AHRQ
WebM&M Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: Julia Munsch,…
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psnet.ahrq.gov/node/49661/psn-pdf
August 01, 2012 - Residual Anesthesia: Tepid Burn
August 1, 2012
Kurrek MM, Twersky RS. Residual Anesthesia: Tepid Burn. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn
The Case
A 42-year-old Filipino man presented to an outpatient surgery center for scheduled repair of an anal fistula.
The pat…
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psnet.ahrq.gov/node/866846/psn-pdf
September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 24, 2024
Stockmeier CA, Thomas E, Mossburg S, et al. Zero Harm: Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/zero…
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psnet.ahrq.gov/web-mm/toxic-tachycardia
March 01, 2005 - Toxic Tachycardia
Citation Text:
Wartofsky L. Toxic Tachycardia. 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 RIS …