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psnet.ahrq.gov/node/49390/psn-pdf
February 01, 2003 - Flying Object Hits MRI
February 1, 2003
Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/flying-object-hits-mri
The Case
A child was brought to the Magnetic Resonance Imaging (MRI) room for a brain scan. Accompanied by an
anesthesiologist, the child was receiving…
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psnet.ahrq.gov/node/49697/psn-pdf
December 01, 2013 - Check the Anesthesia Machine
December 1, 2013
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/check-anesthesia-machine
The Case
A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension,
diabetes, sleep apnea…
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides4.html
October 01, 2017 - Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization
Slide Presentation
Slide 1: How To Implement the Pressure Injury Prevention Program in Your Organization
ADD Hospital Name here
Module 4
Slide 2: What We Have Done Thus Far
Up to this point, you have:
Look…
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www.ahrq.gov/hai/cauti-tools/archived-webinars/patient-family-centered-care-slides.html
December 01, 2017 - Patient and Family-Centered Care
Slide Presentation
Slide 1
Patient and Family-Centered Care
Christine Goeschel ScD, MPA, MPS, RN, FAAN
Assistant Professor, Johns Hopkins School of Medicine
Joint Appointment, Schools of Public Health and Nursing
And
Gail Panoff
Chair, Patient and Community Engage…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/PCMH/adult-eng-cg30-pcmh-2352a.docx
October 30, 2020 - CAHPS Clinician & Group Adult Survey 3.0
CAHPS® Clinician & Group Survey with Patient-Centered Medical Home Items
Version: 3.0
Population: Adult
Language: English
Notes
· Patient-Centered Medical Home (PCMH) items. This version of the Clinician & Group Survey includes the 3.0 version of PCMH items. PCMH item…
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www.ahrq.gov/sites/default/files/wysiwyg/patients-consumers/diagnosis-treatment/treatments/btpills/btpills.pdf
September 01, 2015 - Blood Thinner Pills: Your Guide to Using Them Safely
Blood Thinner Pills:
Your Guide to Using
Them Safely
AHRQ Pub. No. 15-0047-C
Replaces AHRQ Pub. No. 09-0086-C
September 2015
The name of my blood thinner is:
_____________________________________________________________
Reminders:
Call your doctor or phar…
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psnet.ahrq.gov/node/49428/psn-pdf
January 01, 2004 - To Resuscitate or Not?
January 1, 2004
Wu AW, Pronovost P. To Resuscitate or Not? PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/resuscitate-or-not
The Case
A critically ill end-stage AIDS patient was hospitalized for end-of-life care. Given the state of his disease,
his code status was Do Not Resuscitate/…
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psnet.ahrq.gov/node/33644/psn-pdf
December 01, 2006 - Establishing a Safety Culture: Thinking Small
December 1, 2006
Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
Perspective
Safety cultures are the holy grail in any risky industry. Like all holy grails, th…
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psnet.ahrq.gov/Webmm/submit-case-info
August 10, 2025 - Selection Criteria and Honorarium Information
How it works
Health care professionals may submit de-identified cases that highlight medical errors or other patient
safety/quality
issues. Note that you can choose to submit cases either …
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psnet.ahrq.gov/primer/measurement-patient-safety
September 15, 2024 - Measurement of Patient Safety
Citation Text:
Measurement of Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
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psnet.ahrq.gov/node/33593/psn-pdf
June 15, 2024 - Measurement of Patient Safety
June 15, 2024
Measurement of Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/measurement-patient-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient …
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psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary
Save
Save to your library
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February 26, 2025
Innovation
Contact
…
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psnet.ahrq.gov/perspective/patient-engagement-safety
January 01, 2018 - Annual Perspective
Patient Engagement in Safety
Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2017
View more articles from the same authors.
Citation Text:
Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. Rockville (MD): Agency…
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psnet.ahrq.gov/node/867845/psn-pdf
February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step
Technique Innovation Summary
February 26, 2025
https://psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-
summary
Summary
This innovation describes the Veteran Health Administration (VHA) National Center for Patient Saf…
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psnet.ahrq.gov/web-mm/informed-or-misled
April 24, 2018 - Informed or Misled?
Citation Text:
White SM. Informed or Misled?
. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
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psnet.ahrq.gov/node/49773/psn-pdf
July 01, 2016 - Near Miss With Neonate
October 1, 2016
Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/near-miss-neonate
The Case
A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm
dates. Early the next morning, intravenous oxy…
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psnet.ahrq.gov/node/49866/psn-pdf
June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the
Operating Room
June 1, 2019
Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
The Case
A 43-year-old woman was admi…
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psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md
August 01, 2010 - I mean, how often when a patient is scheduled to be in a cath lab at 10:00 AM does it actually happen
-
psnet.ahrq.gov/node/50614/psn-pdf
October 30, 2019 - long) was that no
one was going to read a document that lengthy to make a decision that needed to happen
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/handouts2.html
December 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention
Pressure Ulcer Prevention Handouts (continued)
Implementation of the Prevention Reports Into Day-to-Day Practice
Review of the Change Team's Process of Choosing On-Time Reports, Incorporating Them Into Huddles and Meetings, and Pilot…