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9481. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836978/psn-pdf
      May 16, 2022 - Check Twice, Transport Once May 16, 2022 DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/check-twice-transport-once The Case Case #1: A 26-year-old woman (Patient A) presented to the Emergency Department (ED) with abdominal pain and was diagnosed with “s…

9482. Good Night's Sleep Gone Wrong | PSNet
      psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
      September 01, 2015 - Good Night's Sleep Gone Wrong Citation Text: Gillis CM, Degrado J, Anger KE. Good Night's Sleep Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML…

9483. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50389/psn-pdf
      September 25, 2019 - Getting the Diagnosis Both Right and Wrong September 25, 2019 Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong The Case A 27-year-old woman with a history of acute myeloid leukemia was sent to the emergency department…

9484. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
      August 01, 2014 - PowerPoint Presentation Spotlight Pitfalls in Diagnosing Necrotizing Fasciitis This presentation is based on the July/August 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Terence Goh, MBBS, Department of Plastic Surgery, Singapore General Hos…

9485. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49495/psn-pdf
      December 01, 2005 - Low on the Totem Pole December 1, 2005 Wachter R. Low on the Totem Pole. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/low-totem-pole Case Objectives Understand the concept of authority gradient List steps that can be taken to increase communication across an authority gradient Consider the current cultu…

9486. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33731/psn-pdf
      June 01, 2012 - An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up June 1, 2012 Wachter R. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom Perspecti…

9487. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49554/psn-pdf
      January 01, 2008 - Chemotherapy Extravasation January 1, 2008 Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/chemotherapy-extravasation The Case A 73-year-old woman with no past medical history was diagnosed with stage IIIA breast cancer. She and her oncologist decided to begin sys…

9488. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49432/psn-pdf
      February 09, 2004 - Delay in Initiating Antibiotics Results in Fatal Error February 1, 2004 Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error Case Objectives Understand the importance of ongoing patient re-evaluati…

9489. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49706/psn-pdf
      January 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue April 1, 2014 Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue The Case A 24-year-old wom…

9490. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61079/psn-pdf
      October 28, 2020 - When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication October 28, 2020 Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon- …

9491. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60543/psn-pdf
      May 27, 2020 - Wrong Catheter in the Right Patient May 27, 2020 Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/wrong-catheter-right-patient The Case  A 55-year-old man with history of emphysema was admitted to the hospital for pneumonia. The patient had two?peripheral…

9492. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33642/psn-pdf
      November 01, 2006 - In Conversation With...Donald A. Norman, PhD November 1, 2006 In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background. How did you become interested…

9493. Implementation Quick Start Guide: Teach-back (Half-page) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/teach-back_quickstart_brochure.pdf
      September 15, 2016 - Implementation Quick Start Guide: Teach-back (Half-page) Implementation Quick Start Guide Teach-back The Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Table of Contents What Is Teach-Back? ...........................................................1 Why Use T…

9494. Measure Descriptions for Daily Early Mobility: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/technical/daily-early-mobility-fac-guide.html
      February 01, 2017 - Measure Descriptions for Daily Early Mobility: Facilitator Guide AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: Measure Descriptions for Daily Early Mobility Say: In this module, you will learn about the data measures you will use to evaluate early mobility process and outcome measure…

9495. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Umbilical Cord Prolapse (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_cord-prolapse.docx
      May 01, 2017 - AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Umbilical Cord Prolapse AHRQ Safety Program for Perinatal Care Labor and Delivery Unit Safety Umbilical Cord Prolapse Labor and Delivery Unit Safety—Umbilical Cord Prolapse Purpose of the tool: This tool describes the key perinatal safety elements …

9496. Rapidresponse Facguide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse_facguide.docx
      May 01, 2017 - AHRQ Safety Program for Perinatal Care Rapid Response for Perinatal Safety Rapid Response for Perinatal Safety SAY: The Rapid Response for Perinatal Safety bundle provides information establishing a unitwide approach, also referred to as a rapid response system, for responding to urgent maternity care issues. Slide …

9497. Background and Information for Translators of the AHRQ Hospital Survey on Pateint Safety Culture Version 2.0 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/sops-hsops-2-translation-guidelines.pdf
      August 01, 2023 - Background and Information for Translators of the AHRQ Hospital Survey on Pateint Safety Culture Version 2.0 Agency for Healthcare Research and Quality (AHRQ) Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey Version 2.0 Background and Information for Translators August 2023 Purpose and Use of This…

9498. Optimizing Display of Blood Pressure Data To Support Clinical Decision Making | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/optimizing-display-blood-pressure-data-support-clinical-decision-making
      January 01, 2024 - Optimizing Display of Blood Pressure Data To Support Clinical Decision Making Project Final Report ( PDF , 812.06 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily repres…

9499. State and Regional Demonstration in Health Information Technology: Tennessee | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/state-and-regional-demonstration-health-information-technology-tn
      January 01, 2023 - State and Regional Demonstration in Health Information Technology: Tennessee Project Final Report ( PDF , 2.12 MB) Disclaimer Disclaimer (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact ahrqsection508@…

9500. Health Information Exchange | Digital Healthcare Research
      digital.ahrq.gov/health-information-exchange-2
      January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…