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psnet.ahrq.gov/web-mm/x-ray-flip
August 10, 2019 - X-ray Flip
Citation Text:
Shapiro MJ. X-ray Flip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downl…
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www.ahrq.gov/hai/cusp/modules/implement/alt-text.html
April 01, 2013 - Implement Teamwork and Communication Alternative Text
Slide Number and Title
Slide Content
Content for Alternative Text (Illustration)
Slide 1
Cover Slide
(CUSP Toolkit logo)
The “Teamwork and Collaboration” module of the CUSP Toolkit. The CUSP toolkit is a modular approach to patient sa…
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psnet.ahrq.gov/web-mm/patient-mix
December 01, 2007 - Patient Mix-Up
Citation Text:
Shojania KG. Patient Mix-Up. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/web-mm/situational-unawareness
August 01, 2009 - Situational (Un)Awareness
Citation Text:
Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
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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/related_files/hnhc-disposition-comments.pdf
October 29, 2021 - Disposition of Comments_Comparative Effectiveness Review No. 246: Management of High-Need, High-Cost Patients: A "Best Fit" Framework Synthesis, Realist Review, and Systematic Review
Comparative Effectiveness Review Disposition of Comments Report
Title: Management of High-Need, High-Cost Patients: A “Best…
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effectivehealthcare.ahrq.gov/sites/default/files/communicating_risk_media_wilkes.ppt
April 01, 2006 - THIS IS OUR TEACHER!
Communicating the Harms and Benefits of Medical Treatments: a look from both sides of the aisle…
Prepared by michael wilkes and richard kravitz
We learn about medicine through the media
Press coverage is too often inaccurate, superficial, or sensationalized.
Some of the most import…
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psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
January 01, 2021 - Spotlight
Spotlight
The Consequences of Miscommunication
Regarding a Possible Artifact
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Kriti Gwal, MD
o AHRQ WebM&M Edit…
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psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
June 16, 2021 - Looking for Meds in All the Wrong Places
Citation Text:
Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
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psnet.ahrq.gov/node/865697/psn-pdf
April 24, 2024 - In Conversation with...Katie Boston-Leary about Patient
Safety Amid Nursing Workforce Challenges
April 24, 2024
Leary KB. In Conversation with..Katie Boston-Leary about Patient Safety Amid Nursing Workforce
Challenges. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-a…
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psnet.ahrq.gov/node/49614/psn-pdf
November 01, 2010 - Reconciling Records
November 1, 2010
Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/reconciling-records
The Cases
Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local
teaching hospital. When discharged, h…
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www.ahrq.gov/funding/training-grants/hsrguide/hsrguide1.html
October 01, 2014 - An Organizational Guide to Building Health Services Research Capacity
Step 1: Assessing Your Organization's Needs and Capabilities
Previous Page Next Page
Table of Contents
An Organizational Guide to Building Health Services Research Capacity
Introduction
Step 1: Assessing Your Organization's Ne…
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www.ahrq.gov/hai/tools/mvp/modules/cusp/physician-staff-engagement-facguide.html
March 01, 2017 - Physician and Staff Engagement: Facilitator Guide
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: Physician and Staff Engagement
Say:
Today, we will give you an overview of physician and staff engagement.
Slide 2: Learning Objectives
Say:
After this session, you will be able to…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/implement-slides.html
July 01, 2023 - Implement Teamwork and Communication for Perinatal Safety
AHRQ Safety Program for Perinatal Care
Slide 1: AHRQ Safety Program for Perinatal Care
Implement Teamwork and Communication for Perinatal Safety
Slide 2: Learning Objectives
Image: Four ascending steps show the learning objectives:
Recogn…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_sustspreading.pptx
December 01, 2017 - Presentation: Sustaining and Spreading Surgical Improvments
Sustaining and Spreading Surgical Safety Improvements
AHRQ Safety Program for Surgery
Sustainability
AHRQ Pub. No. 16(18)-0004-15-EF
December 2017
AHRQ Safety Program for Surgery – Sustainability
SAY:
This module will cover Sustaining and Spreading Surgic…
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-1-slides.pdf
January 30, 2020 - Module 1 Slides: Welcome to the TAKEheartInitiative and the Benefits of Increasing Cardiac
Welcome to the TAKEheart
Initiative and the Benefits
of Increasing Cardiac
Rehabilitation Participation
L e a r n i n g C o m m u n i t y W e b i n a r S e r i e s :
R a n d a l T h o m a s , M D M S
K a r e n L u i , …
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psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - Refused Medication Error
February 1, 2017
Foley M. Refused Medication Error. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was
alert to self and place only. The patient h…
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psnet.ahrq.gov/node/49629/psn-pdf
June 01, 2011 - Say It Again
June 1, 2011
Henriksen K, Hall KK. Say It Again. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/say-it-again
The Case
A 72-year-old man was admitted to the hospital with community-acquired pneumonia and hyponatremia.
During his third hospital night, the on-call physician was contacted by the c…
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www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/measures/measure-2.html
November 01, 2017 - Established Child Health Care Quality Measures—CAHPS
Child Health Care Quality Toolbox
The Child Health Toolbox contains concepts, tips, and tools for evaluating the quality of health care for children.
Contents
Expanded CAHPS 3.0 Child Survey
Children with Chronic Conditions
Screener Questions
…
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psnet.ahrq.gov/node/49802/psn-pdf
August 01, 2017 - Add-on Case and the Missing Checklist
August 1, 2017
Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
The Case
A 65-year-old woman was admitted for evaluation of abdominal pain and weight loss. Based on diagnostic
data and ima…