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psnet.ahrq.gov/web-mm/forgotten-radiographic-read
June 07, 2016 - The Forgotten Radiographic Read
Citation Text:
Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one
April 24, 2018 - Written Signout: It Only Works If You Use The Right One
Citation Text:
Lewis K, Rosenbluth G. Written Signout: It Only Works If You Use The Right One. 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/49817/psn-pdf
January 01, 2018 - Slow Down: Right Drug, Wrong Formulation
January 1, 2018
Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
The Case
A 65-year-old man presented to his primary care clinic for follow-up after a recent hospitaliz…
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psnet.ahrq.gov/node/852699/psn-pdf
August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety
August 30, 2023
Van CM, Mossburg S, McGaffigan P. Beyond the Pandemic: Creating Total Systems Safety. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
The COVID-19 pandemic necessitated a shift in operations …
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs024349-mcalearney-final-report-2017.pdf
January 01, 2017 - Portals in Inpatient Care: Evaluating the Usability, Use, and Patient Experience Associated With Patient Portal Technology at the Bedside - Final Report
Portals in inpatient care (PIC): Evaluating the usability, use an…
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psnet.ahrq.gov/node/33660/psn-pdf
December 01, 2007 - In Conversation with...Eric Coleman, MD, MPH
December 1, 2007
In Conversation with..Eric Coleman, MD, MPH. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
Editor's Note: Eric A. Coleman, MD, MPH, is Associate Professor of Medicine at the University of
Colorado. Train…
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psnet.ahrq.gov/node/49583/psn-pdf
April 01, 2009 - Eptifibatide Epilogue
April 1, 2009
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/eptifibatide-epilogue
The Case
A 62-year-old man was admitted at 11:00 PM on a Saturday night with the provisional diagnosis of acute
coronary syndrome. Serial testing for mark…
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psnet.ahrq.gov/node/33711/psn-pdf
May 01, 2011 - The Second Victim Phenomenon: A Harsh Reality of
Health Care Professions
May 1, 2011
Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [internet].
2011.
https://psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
Perspective
The Instit…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/19-perioperative-teams.docx
June 01, 2023 - A Guide to Leading Successful Perioperative TeamsAHRQ Safety Program for Improving Surgical Care and Recovery
Purpose of the tool: Assembling a multidisciplinary perioperative team is one of the first, and most critical, steps in your AHRQ Safety Program for Improving Surgical Care and Recovery (ISCR) journey. This do…
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psnet.ahrq.gov/node/60609/psn-pdf
June 24, 2020 - When the Indications for Drug Administration Blur
June 24, 2020
Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accre…
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/amplify-impact-webinar.html
October 01, 2020 - Amplify Your Impact on Child Health Care Quality
Learning from the CHIPRA Quality Demonstration Grant Program
On February 11, 2016, AHRQ and CMS presented a free Webinar, "Amplify Your Impact on Child Health Quality: Learning from the CHIPRA Quality Demonstration Grant Program." The presentations featured hig…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/training/cbt-basin-bathing.pptx
March 01, 2022 - Computer-Based Training Modules: Basin Bed Bathing with CHG
Decolonization of
Non-ICU Patients With Devices
Section 11-6
Nursing Protocol Training
Basin Bed Bathing With 2% Chlorhexidine (CHG)
and Showering With 4% CHG Liquid Soap
AHRQ Pub. No. 20(22)-0036
March 2022
1
Targeted Decolonization Introduction
Our…
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psnet.ahrq.gov/node/49856/psn-pdf
March 01, 2019 - Premature Extubation
March 1, 2019
Sagana R, Hyzy RC. Premature Extubation. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/premature-extubation
The Case
A 73-year-old woman with a history of carotid artery stenosis was admitted for an elective carotid
endarterectomy. The procedure was initially thought to …
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-tool.html
July 01, 2023 - Monitoring for Perinatal Safety: Electronic Fetal Monitoring
AHRQ Safety Program for Perinatal Care
Purpose of the tool: This tool describes the key perinatal safety elements that support the use of electronic fetal monitoring (EFM). The key safety elements are presented within the framework of t…
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psnet.ahrq.gov/node/50929/psn-pdf
February 26, 2020 - Discharged with IV antibiotics: When issues arise, who
manages the complications?
February 26, 2020
Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the
complications? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-…
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digital.ahrq.gov/program-overview/research-reports/2023-year-review/research-themes-and-findings
January 01, 2023 - Research Themes and Findings
The DHR program funds research that demonstrates how digital healthcare solutions can be designed and implemented to improve healthcare system performance and patient health outcomes. Our funded research focuses on advancing patient safety, care, and shared decis…
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psnet.ahrq.gov/web-mm/2-week-itch
June 16, 2019 - The 2-Week Itch
Citation Text:
Cohen MR. The 2-Week Itch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
April 24, 2018 - The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps
Citation Text:
Sauder C, Kleber KT. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/49490/psn-pdf
September 01, 2005 - The Wrong Channel
September 1, 2005
Gosbee JW. The Wrong Channel . PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/wrong-channel
The Case
A 28-year-old woman in labor began receiving treatment with magnesium sulfate for preeclampsia. Initial
dosing started at 50 mL/hour using a multi-channel medication pump…
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effectivehealthcare.ahrq.gov/sites/default/files/eaagleston.pdf
May 29, 2025 - American Medical Association (AMA) App Challenge and AMA Idealab
INNOVATIONS CONFERENCE -- AMA
SPEAKERS: ROBERT HICKS,
BUSINESS PROCESS DEVELOPMENT DIRECTOR,
AMA
BRIAN EAGGLESTON,
PHYSICIAN OUTREACH AND RETENTION,
AMA
HICKS: I'm Bob Hicks. I'm business process development director …