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psnet.ahrq.gov/node/49485/psn-pdf
August 29, 2024 - Blind Spot
June 1, 2005
Lee LA. Blind Spot. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/blind-spot
The Case
A 36-year-old woman with no significant past medical history underwent right nephrectomy in the left lateral
position. The surgery was uncomplicated—her blood pressures intraoperatively were withi…
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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…
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psnet.ahrq.gov/node/49864/psn-pdf
June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You
in Training About Feedback and Burnout
June 1, 2019
Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About
Feedback and Burnout. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…
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www.ahrq.gov/research/findings/final-reports/stpra/stpraapd.html
April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Appendix D. Site Visit Process Comparison
Previous Page Next Page
Table of Contents
Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Executive Summary
Chapter 1. Introduction
Ch…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/microbiologic-specimens-facilitator-guide.docx
June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use
1
Appropriate Collection of Microbiologic Specimens
Long-Term Care
Slide Title and Commentary
Slide Number and Slide
Appropriate Collection of Microbiologic Specimens
Long-Term Care
SAY:
Welcome to this presentation, titled, “Appropriate Collection of Microbiol…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-removal-notes.docx
April 01, 2022 - Prompting Removal of Unnecessary Indwelling Urinary Catheters Facilitator Notes
CAUTI Module:
Indwelling Urinary Catheter Removal
Facilitator Guide
Slide Number and Image
This module, titled “Indwelling Urinary Catheter Removal,” is part of the Agency for Healthcare Research and Quality’s Safety Program for In…
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www.ahrq.gov/hai/tools/mvp/modules/technical/intro-daily-care-facguide.html
February 01, 2017 - Introduction to Daily Care Processes: Evidence Behind Spontaneous Awakening Trials, Spontaneous Breathing Trials, and Head of Bed Elevation: Facilitator Guide
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: Introduction to Daily Care Processes: Evidence Behind Spontaneous Awakening Trials, S…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/040-mrsa-surveillance-notes.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
MRSA Surveillance
ICU & Non-ICU
Slide Title and Commentary
Slide Number and Slide
MRSA Surveillance
SAY:
Welcome to this presentation on MRSA Surveillance, which will explain how various approaches to MRSA surveillance help to prevent transmission of MRSA in intensive care u…
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www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6o.html
June 01, 2014 - Care Coordination Measures Atlas Update
Chapter 6. Measure Maps and Profiles (continued, 16)
Previous Page Next Page
Table of Contents
Care Coordination Measures Atlas Update
Chapter 1: Background
Chapter 2. What is Care Coordination?
Chapter 3. Care Coordination Measurement Framework
Chapte…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/001-ss-antimicrobial-prophylaxis-1-fg.docx
April 01, 2025 - AHRQ Safety Program for MRSA
Prevention: Targeting SSI
Antimicrobial Prophylaxis: Part 1
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
Slide Title and Commentary
Slide Number and Slide
Antimicrobial Prophylaxis: Part 1
SAY:
Hello. Welcome to this presentation on antim…
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www.ahrq.gov/sites/default/files/2024-04/wolfson-report.pdf
January 01, 2024 - Final Progress Report: Conference: Physician-Level Interventions: What Works to Improve Quality of Care
Conference:
Physician-Level Interventions:
What Works to Improve Quality of Care
Principal Investigator: Daniel Wolfson
Team Members: Christine Cassel, Ann Greiner, Eric Holmboe
Organization: American Board of…
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www.ahrq.gov/es/patient-safety/settings/hospital/match/chapter-3.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Chapter 3. Developing Change: Designing the Medication Reconciliation Process
Previous Page Next Page
Table of Contents
Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Recon…
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www.ahrq.gov/sites/default/files/publications2/files/dx-issue-brief-20-brazil-health-system.pdf
August 01, 2024 - Learning from AHRQ's Diagnostic Safety Culture Survey at a Tertiary Care Health System in Brazil: A Case Study
PATIENT
SAFETY
e
Issue Brief 20
Learning from AHRQs’ Diagnostic Safety
Culture Survey at a Tertiary Care Health
System in Brazil: A Case Study
This page intentionally left blank.
e
Issue Brief 2…
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www.ahrq.gov/patient-safety/settings/hospital/match/chapter-3.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Chapter 3. Developing Change: Designing the Medication Reconciliation Process
Previous Page Next Page
Table of Contents
Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Recon…
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www.ahrq.gov/hai/cauti-tools/archived-webinars/preventing-cauti-proc-related-catheter-use-slides.html
December 01, 2017 - Preventing CAUTI in Special Populations: Focus on Procedure-Related Catheter Use
Slide presentation
Slide 1
Preventing CAUTI in Special Populations: Focus on Procedure-Related Catheter Use
David A. Pegues, MD
Professor of Medicine, Division of Infectious Diseases
Medical Director, Healthcare Epidemiol…
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www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
December 01, 2017 - Learning From Defects Through Sensemaking: Slide Presentation
AHRQ Safety Program for Surgery
Slide 1: AHRQ Safety Program for Surgery—Implementation
Learning From Defects through Sensemaking
Slide 2: Learning Objectives
Describe difference between first-order and second-order problem-solving.
L…
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psnet.ahrq.gov/node/865376/psn-pdf
March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a
Patient Admitted for Leg Fractures
March 27, 2024
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…
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psnet.ahrq.gov/node/49540/psn-pdf
August 21, 2007 - Resuscitation Errors: A Shocking Problem
August 21, 2007
Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
Case Objectives
Appreciate that delays in defibrillation can have significant negative effects on sur…
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psnet.ahrq.gov/node/49508/psn-pdf
January 01, 2007 - Language Barrier
April 1, 2006
Flores G. Language Barrier. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/language-barrier
The Case
A previously healthy 10-month-old girl was taken to a pediatrician's office by her monolingual Spanish-
speaking parents when they noted that their daughter had generalized we…
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psnet.ahrq.gov/node/33674/psn-pdf
February 01, 2009 - In Conversation with…Robert M. Wachter, MD
October 1, 2008
In Conversation with…Robert M. Wachter, MD. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
Editor's note: At the University of California, San Francisco, Robert M. Wachter, MD, is Professor and
Chief of the…