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psnet.ahrq.gov/node/867475/psn-pdf
February 26, 2025 - From Pain Relief to Risk: A Case of Suspected Opioid
Overdose in a Pediatric Patient
February 26, 2025
Markham K, Usui M, Smith C. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a
Pediatric Patient. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overd…
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psnet.ahrq.gov/node/49531/psn-pdf
March 01, 2007 - Failure to Report
March 1, 2007
Spath P. Failure to Report. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/failure-report
Case Objectives
List common causes of medical errors.
Appreciate the magnitude of underreporting of adverse events.
List the common barriers to reporting adverse events and near misses…
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www.ahrq.gov/sites/default/files/2024-03/connolly-report.pdf
January 01, 2024 - Final Progress Report: Topical Vancomycin for Neurosurgery Wound Prophylaxis
Title: Topical Vancomycin for Neurosurgery Wound Prophylaxis
Principal Investigator: Connolly, Edward Sander
Team Members:
Jared Knopman, MD - Site PI (Cornell)
Emilia Bagiella, PhD - Site PI (Mount Sinai)
Franklin Lowy, MD - Co-Investigato…
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www.ahrq.gov/sites/default/files/2024-01/abraham-report.pdf
January 01, 2024 - Final Progress Report: Gastrointestinal Safety of Antithrombotic Drug Regimens
1
Project Title: Gastrointestinal Safety of Antithrombotic Drug Regimens
Grant Number: 5RO1HSO25402-04
Principal Investigator: Neena S. Abraham, MD
Team Members:
Xiaoxi Yao, PhD
Nilay Shah, PhD
Peter Noseworthy, MD
Jeph Herrin, Ph…
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psnet.ahrq.gov/node/49669/psn-pdf
November 01, 2012 - Transfusion Overload
November 1, 2012
Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfusion-overload
Case Objectives
Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit
below 30% are not supported by the evidence.…
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psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
September 01, 2017 - Missed Patient Assignment: Is Anyone There?
Citation Text:
Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
Copy Citation
Format:
Google …
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/implementation-guides/implementation-guide1/impguide1step3.html
March 01, 2019 - Step 3: Build the Stakeholder Group Structure
Implementation Guide Number 1
This Implementation Guide includes suggested steps and tips for implementing initiatives for improving child health care quality from the CMS-funded national evaluation of the Children’s Health Insurance Program Reauthorization Act of…
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/member-codebook-6mon-post-intervention.pdf
January 01, 2014 - Practice Member Survey Code Book
Practice Member Survey Code Book
Variable / Core-optional
Status
Item Timing
The purpose of this survey is t…
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/cpcq-scoring.pdf
May 01, 2017 - Scoring CPCQ
1
Scoring the Change Process Capability
Questionnaire Strategies Items:
Current Plan
National Evaluation Team
May 1, 2017
2
Introduction
The RFA from AHRQ for EvidenceNOW:
http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-14-008.html
described the required measures of practice…
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psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overdose-pediatric-patient
October 04, 2023 - From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient
Citation Text:
Markham K, Usui M, Smith C. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of…
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psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
December 15, 2024 - Deprescribing as a Patient Safety Strategy
Citation Text:
Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
Copy Citation
Format:
Google Scholar BibTeX …
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psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose
Citation Text:
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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www.ahrq.gov/ncepcr/tools/confid-report/physfeedback.html
February 01, 2016 - Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance
Part One: Physician Feedback Report Fundamentals
Previous Page Next Page
Table of Contents
Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance
Foreword
Introduction
Part One: P…
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www.ahrq.gov/hai/tools/mvp/modules/cusp/forming-cusp-team-fac-guide.html
February 01, 2017 - Forming a Comprehensive Unit-based Safety Program Team: Facilitator Guide
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: Forming a Comprehensive Unit-based Safety Program Team
Say:
Today, we will briefly revisit the key concepts of the Comprehensive Unit-based Safety Program or CUSP. …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/forming-cuspteam-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Forming a Comprehensive Unit-based Safety Program Team
SAY:
Today, we will briefly revisit the key concepts of the Comprehensive Unit-based Safety Program or CUSP. Then, we will dive into a focused di…
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/building-team-process-slides.html
December 01, 2017 - Building a Team and Process to Reduce CAUTI Risk
Slide Presentation
Slide 1
Mohamad Fakih, MD, MPH
Professor of Medicine
Wayne State University School of Medicine
Medical Director, Infection Prevention and Control
St. John Hospital and Medical Center
Barbara Lucas, MD, MHSA
Project Consultant
Mich…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/sustainability/sustaining-guide.pdf
March 01, 2017 - Guide to Sustaining a Program To Reduce Catheter-Associated Urinary Tract Infections in Long-Term Care
AHRQ Safety Program for
Long-Term Care: HAIs/CAUTI
Guide to Sustaining a Program To Reduce
Catheter-Associated Urinary Tract
Infections in Long-Term Care
AHRQ Public…
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www.ahrq.gov/sites/default/files/2024-02/leapfrog-report.pdf
January 01, 2024 - Final Progress Report: The P4P Decision Tool: A Stakeholder Guide to Exploring and Selecting an Appropriate Pay-for-Performance Program
The P4P Decision Tool:
A Stakeholder Guide to Exploring and Selecting
an Appropriate Pay-for-Performance Program
Supported by a grant from the Agency for Healthcare Research and …
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www.ahrq.gov/sites/default/files/2024-02/whitney-report.pdf
January 01, 2024 - Final Progress Report: A new approach to the allocation of decisional authority
FINAL REPORT
A new approach to the allocation of decisional authority
Simon Whitney, MD, JD, Principal Investigator
Team members
Robert Volk, PhD, vice chair for research, Baylor College of Medicine, Department of
Family …
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt1.pdf
October 01, 2015 - QDR 2014: Chartbook for Hispanic Health Care, Part 1
Agency for Healthcare Research and Quality
Advancing Excellence in Health Care www.ahrq.gov
2014 National Healthcare
Quality and Disparities Report
CHARTBOOK ON
HEALTH CARE
FOR HISPANICS
This document is in the public domain and may be used and reprinte…