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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…
-
psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Intraosseous Line Extravasation in a
Pediatric Trauma Patient
Source and Credits
• This presentation is based on the April 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: David Barnes, MD and Joseph Yoon, MD
o…
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psnet.ahrq.gov/sites/default/files/2020-05/webmm.ahrq_.gov_.392_slideshow.pptx
January 01, 2020 - Spotlight
Spotlight
Suicidal Ideation in the Family Medicine Clinic
1
Source and Credits
This presentation is based on the December 2016
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Christine Moutier, MD, Chief Medical Officer, American …
-
psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx
Spotlight
Premature Closure: Was it Just Syncope?
Source and Credits
• This presentation is based on the November 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit i…
-
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,…
-
psnet.ahrq.gov/sites/default/files/2022-05/final_cme_reviewed_-_spotlight_missing_a_large_vessel_occlusion_stroke_04.14.2022_-_copy.pdf
January 01, 2022 - Spotlight
Spotlight
Missing a Large Vessel Occlusion Stroke in
a Patient with a History of Seizures
Source and Credits
• This presentation is based on the May 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Kevin Keenan, MD and D…
-
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. …
-
psnet.ahrq.gov/node/73852/psn-pdf
October 27, 2021 - [Free full text]
https://med.umn.edu/covid-fatigue/minnrap
https://psnet.ahrq.gov/sites/default/files … /2021-09/Battle%20buddies%20tip%20sheet%20%281%29.pdf
https://psnet.ahrq.gov/sites/default/files/2021 … -09/Battle%20Buddy%20Pocket%20Card%20-%20final%20%281%29.pdf
https://psnet.ahrq.gov/sites/default/files
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psnet.ahrq.gov/node/73643/psn-pdf
August 01, 2022 - psnet.ahrq.gov//#2
https://psnet.ahrq.gov//#2
https://psnet.ahrq.gov//#3
https://www.bidmc.org/-/media/files … https://www.bidmc.org/-/media/files/beth-israel-org/research/research-by-department/medicine/gerontology … /echo-care/moore_echoct.pdf
https://www.bidmc.org/-/media/files/beth-israel-org/research/research-by-department … 234427/hospital-medicine/echo-ct-interdisciplinary-videoconference-model
https://www.bidmc.org/-/media/files … research-by-department/medicine/gerontology/echo-care/moore_echoct.pdf
https://www.bidmc.org/-/media/files
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psnet.ahrq.gov/node/61082/psn-pdf
July 23, 2020 - psnet.ahrq.gov//#_edn5
https://psnet.ahrq.gov//#_edn6
https://psnet.ahrq.gov//#_edn7
https://www.cms.gov/files … /document/qso-20-39-nh.pdf
https://www.cms.gov/files/document/qso-20-39-nh.pdf
https://psnet.ahrq.gov … CDC_AAref_Val=https://www.cdc.gov/longtermcare/training.html
https://www.cms.gov/files/document/qso-20 … press-releases/cms-issues-nursing-homes-best-practices-toolkit-combat-covid-19
https://edit.cms.gov/files … Centers for Medicare & Medicaid Services. https://www.cms.gov/files/document/qso-20-39-nh.pdf.
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psnet.ahrq.gov/node/50928/psn-pdf
February 21, 2020 - https://www.healthit.gov/sites/default/files/safety_plan_master.pdf. Accessed November 19, 2019. … https://healthpolicy.duke.edu/sites/default/files/atoms/files/dukemargolisaienableddxss.pdf. … conference+on+transfusion+outcomes
https://psnet.ahrq.gov//#_ednref12
https://www.hhs.gov/sites/default/files … reduce+adverse+events
https://psnet.ahrq.gov//#_ednref14
https://healthpolicy.duke.edu/sites/default/files … /atoms/files/dukemargolisaienableddxss.pdf
November 19, 2019
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psnet.ahrq.gov/node/74830/psn-pdf
June 01, 2022 - The W.I.S.E Tool for assessment of short term PICC use. https://mi-
hms.org/sites/default/files/WISE … Accessed November 17, 2021. https://mi-
hms.org/sites/default/files/Adult%20Guideline%20for%20Admin% … 20of%20Antibiotics%20via%20Midline%20Catheter.pdf
https://mi-hms.org/sites/default/files/WISE_040716 … The W.I.S.E Tool for assessment of short term PICC use. https://mi-
hms.org/sites/default/files/WISE … CDC_AAref_Val=https://www.cdc.gov/hai/prevent/tap/clabsi.html
https://mi-hms.org/sites/default/files/
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psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
January 01, 2020 - Spotlight
Spotlight
Fatal PCA Opioid-Induced
Respiratory Depression
Source and Credits
• This presentation is based on the May 2020 AHRQ
WebM&M Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: Sarina Fazio, PhD, RN and Rachelle
Firestone, PharmD, BCCCP
o Editors in Chie…
-
psnet.ahrq.gov/sites/default/files/2020-04/spotlight-slides-wright-schiff.pdf
January 01, 2020 - Spotlight
The Lost Start Date, an Unknown
Risk of E-prescribing
Source and Credits
• This presentation is based on the October 2019
AHRQ WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Adam Wright, PhD, and Gordon
Schiff, MD
○ Editor, AHRQ…
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psnet.ahrq.gov/sites/default/files/2021-09/Roll-out%20diagram%20generic.pdf
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How to roll out the Battle Buddy program as part of a psychological resilience intervention
Can stand alone*
Specific nursing unit le…
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - AHRQ PSNet Webinar
AHRQ PSNet Webinar
Making Healthcare Safer (MHS) IV:
Rapid Response Systems and Opioid Stewardship
February 10, 2025
Agenda
2
• Logistics
• Introduction to the Making Healthcare Safer (MHS) IV Reports
• Report 1 – Rapid Response Systems
► Discussion
► PSNet Resources
• Report 2 – Opioi…
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psnet.ahrq.gov/node/73387/psn-pdf
March 17, 2021 - https://www.ahrq.gov/sites/default/files/publications/files/haidesign-summary.pdf
2. … patient_care/public_health/COVID-
https://psnet.ahrq.gov//#_ednref1
https://www.ahrq.gov/sites/default/files … /publications/files/haidesign-summary.pdf
https://psnet.ahrq.gov//#_ednref2
https://psnet.ahrq.gov/issue
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psnet.ahrq.gov/node/866216/psn-pdf
July 10, 2024 - CMS MMS Blueprint Legislative Mandates for Quality Measurement
and Reporting. https://www.cms.gov/files … Quality Background on CMS Patient Safety
Indicators 90. https://www.cms.gov/priorities/innovation/files … , 2024. https://mmshub.cms.gov/about-
quality/quality-at-CMS/quality-programs
https://www.cms.gov/files … Quality-Rating-Systems-in-Medicaid-Managed-Care.pdf
https://doi.org/10.1089/pop.2021.0197 
https://www.cms.gov/priorities/innovation/files
-
psnet.ahrq.gov/node/846922/psn-pdf
March 29, 2023 - https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf
U.S. … department visits and hospitalizations among chronically ill homeless adults: a
https://innovation.cms.gov/files … https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf
https://www.hfma.org/topics/finance-and-business-strategy … finance-and-business-strategy/article/sdoh-initiative-reduces-readmission-penalties-in-one-year.html
https://innovation.cms.gov/files
-
psnet.ahrq.gov/node/60547/psn-pdf
May 28, 2020 - IMPAQ Health
IMPAQ International
Columbia, MD
https://psnet.ahrq.gov//#_edn3
https://www.fda.gov/files … Food and Drug
Administration. https://www.fda.gov/files/about%20fda/published/Medical-Device-Safety-Action-Plan … consumers-medical-devices#How_are_Medical_Devices_Classified_
https://psnet.ahrq.gov//#_ednref3
https://www.fda.gov/files … Medical-Device-Safety-Action-Plan--Protecting-Patients--Promoting-Public-Health-%28PDF%29.pdf
https://www.fda.gov/files