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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49800/psn-pdf
    July 01, 2017 - The Hidden Harms of Hand Sanitizer July 1, 2017 Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer The Case A 57-year-old woman with a history of alcohol abuse and severe depression was admitted to the hospital for community-acquired pn…
  2. digital.ahrq.gov/sites/default/files/docs/survey/cis-survey-pre-go-live-physician.pdf
    December 27, 2004 - Employee / Staff Pre-Go-Live Expectations / Perceptions Clinical Information Systems Survey Employee and Staff Pre Go-Live Expectations and Perceptions Clinical Information Systems Survey: Physician Only University of Iowa, Iowa City IA This is a questionnaire designed to be completed by physicians in an inpatient…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49698/psn-pdf
    December 01, 2013 - SNFs: Opening the Black Box December 1, 2013 Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/snfs-opening-black-box The Case An 88-year-old woman was admitted to a skilled nursing facility (SNF) after a lengthy hospitalization for a small bowel obstructio…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49606/psn-pdf
    August 01, 2010 - Weighing In on Surgical Safety August 1, 2010 Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/weighing-surgical-safety Case Objectives Identify the comorbidites associated with obesity that place patients at higher risk for surgical complications. Un…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49678/psn-pdf
    March 01, 2013 - A Weighty Mistake March 1, 2013 Bokser SJ. A Weighty Mistake. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/weighty-mistake Case Objectives Understand factors associated with weight-based dosing medication errors in pediatric populations. Describe how adoption of computerized provider order entry (CPOE) s…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49859/psn-pdf
    April 01, 2019 - E-cigarette Explosion in a Patient Room April 1, 2019 Benowitz NL. E-cigarette Explosion in a Patient Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room The Case A 49-year-old woman was admitted for an exacerbation of chronic obstructive pulmonary disease (COPD) without…
  7. psnet.ahrq.gov/web-mm/renal-failure-due-benign-prostatic-hyperplasia
    February 01, 2004 - Renal Failure Due to Benign Prostatic Hyperplasia Citation Text: Barry MJ, Garnick MB. Renal Failure Due to Benign Prostatic Hyperplasia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google…
  8. psnet.ahrq.gov/web-mm/its-sarah-not-stephen
    January 01, 2015 - SPOTLIGHT CASE It's Sarah, Not Stephen! Citation Text: Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…
  9. psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
    August 28, 2024 - Root Cause Analysis Gone Wrong Citation Text: Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49531/psn-pdf
    March 01, 2007 - Failure to Report March 1, 2007 Spath P. Failure to Report. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/failure-report Case Objectives List common causes of medical errors. Appreciate the magnitude of underreporting of adverse events. List the common barriers to reporting adverse events and near misses…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49829/psn-pdf
    May 01, 2018 - Root Cause Analysis Gone Wrong May 1, 2018 Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney transplant. A suitabl…
  12. psnet.ahrq.gov/web-mm/eptifibatide-epilogue
    March 04, 2011 - Eptifibatide Epilogue Citation Text: Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
  13. psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
    August 21, 2024 - Doctor, Don't Treat Thyself Citation Text: Rosvold EO. Doctor, Don't Treat Thyself. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49669/psn-pdf
    November 01, 2012 - Transfusion Overload November 1, 2012 Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfusion-overload Case Objectives Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit below 30% are not supported by the evidence.…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49857/psn-pdf
    March 01, 2019 - Duplicate Insulin Order March 1, 2019 Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/duplicate-insulin-order The Case A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency department (ED) for complaints of letharg…
  16. www.ahrq.gov/faqs/index.html?page=13
    Frequently Asked Questions Check to find the answers to your questions about the Agency for Healthcare Research and Quality (AHRQ) programs and activities. You can search by category or key words. You can also send us your questions or website feedback here. We will respond to your requests based on the bes…
  17. www.ahrq.gov/hai/cauti-tools/archived-webinars/sustaining-change-slides.html
    December 01, 2017 - Sustaining Change Slide Presentation Slide 1 Sustaining Change Eugene S. Chu, MD, FHM Director of Hospital Medicine Boulder Community Health Associate Clinical Professor of Medicine University of Colorado School of Medicine Image: On bottom left of every slide is the CUSP symbol. Slide 2 Lea…
  18. digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/murphy-diagram
    January 01, 2023 - Murphy Diagram Description Murphy diagrams are based on the premise that "if something can go wrong, it will go wrong." They are similar to other analysis methods such as fault trees as they analyze errors based on the potential causes of those errors. The diagrams utilize eight categories of behav…
  19. hcup-us.ahrq.gov/db/nation/nis/APS-DRGsDefManualV25Public.pdf
    June 01, 2009 - In 1994, Ingenix developed the All-Payer Severity-adjusted DRGs (APS-DRGs®) in response to the on-going
  20. psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
    March 01, 2015 - Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? Ian Scott, MBBS, MHA, MEd | March 1, 2015  Also Read a Conversation View more articles from the same authors. Citation Text: Scott IA. Where Does Risk-Adjusted Mortality Fit Into a Safety …