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psnet.ahrq.gov/node/49855/psn-pdf
March 01, 2019 - Which Line: Ordering Provider or Proceduralist?
March 1, 2019
Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
Case Objectives
Review the role of mistake-proofing to block errors from leading to adverse…
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psnet.ahrq.gov/node/49519/psn-pdf
September 01, 2006 - Triple Handoff
September 1, 2006
Vidyarthi A. Triple Handoff. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/triple-handoff
Case Objectives
Appreciate the prevalence of handoffs and sign out related errors.
Understand the key elements of a safe and effective written and verbal sign out.
List Kotter’s 8 st…
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - SPOTLIGHT CASE
The Missing Abscess: Radiology Reads in the Digital Era
Citation Text:
Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. 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/curated-library/interdisciplinary-teamwork
September 15, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Interdisciplinary teamwork
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet T…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/zero_clabsis-slides/Sustaining-Zero-CLABSIs-May-8-2012-508.ppt
January 01, 2012 - Slide 1
Getting to Zero and
Sustaining Success:
The Virginia Experience
Barbara Brown, Vice President
Virginia Hospital and Healthcare Association
May 8, 2012
*
Learning Objectives
To understand the challenges and successes the Commonwealth of Virginia experienced during the national collaborative in
Reduci…
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psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - SPOTLIGHT CASE
Errors in Sepsis Management
Citation Text:
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Learning From Defects
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
Slide Title and Commentary
Slide Number and Slide
Learning From Defects
SAY:
Welcome to this presentation on Learning From Defects as part of an o…
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www.ahrq.gov/ncepcr/reports/2025-annual-report/overview.html
August 01, 2025 - AHRQ’s Investments in Primary Care Research for 2023 and 2024
2. Overview of AHRQ’s Recent Investments in Primary Care Research
Previous Page Next Page
Table of Contents
AHRQ’s Investments in Primary Care Research for 2023 and 2024
Acknowledgements and Authors
Message from the Director of AHRQ…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/hro-protocol.pdf
January 01, 2023 - Making Healthcare Safer IV: High Reliability Organization (HRO) as a Patient Safety Practice
Evidence-based Practice Center Rapid Review Protocol
Project Title: Making Healthcare Safer IV: High Reliability Organization
(HRO) as a Patient Safety Practice
Review Questions
Review Question
Based on t…
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psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
January 29, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia
Citation Text:
Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/disruptive-behavior-disorders-research-executive-summ.pdf
April 01, 2025 - Executive Summary_Systematic Review: Psychosocial and Pharmacologic Interventions for Disruptive Behavior in Children and Adolescents
Systematic Review
Psychosocial and Pharmacologic
Interventions for Disruptive Behavior in
Children and Adolescents
Executive Summary
Main Points
• When po…
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hcup-us.ahrq.gov/reports/statbriefs/sb33.pdf
June 01, 2007 - Statistical Brief #33: Reasons for Being Admitted to the Hospital through the Emergency Department for Children and Adolescents, 2004
HEALTHCARE COST AND
UTILIZATION PROJECT
Agen
Res
June 2007
Reasons for Being Admitted to the
Hospital through the Emergency
Department for Children and
…
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psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - SPOTLIGHT CASE
Prolonged DKA in Pregnancy: A Case of Communication Breakdown.
Citation Text:
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services…
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hcup-us.ahrq.gov/reports/statbriefs/sb20.jsp
December 20, 2006 - Statistical Brief #20
An official website of the Department of Health & Human Services
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Espanol
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hcup-us.ahrq.gov/reports/statbriefs/sb20.pdf
December 01, 2006 - HCUP Statistical Brief #20: Obese Patients in U.S. Hospitals, 2004
HEALTHCARE COST AND
UTILIZATION PROJECT
Agency for Healthcare
Research and Quality
STATISTICAL BRIEF #20
December 2006
Highlights
In 2004, there were 1.7 million
hospital stays during which
obesity was noted, accountin…
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - SPOTLIGHT CASE
Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump
Citation Text:
Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump . PSNet [internet]. Rockville (MD): Agency for Heal…
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www.uspreventiveservicestaskforce.org/uspstf/document/final-evidence-summary12/cervical-cancer-screening-2012
October 18, 2011 - Screening with HPV testing enhances the detection of CIN3+ compared with cytology alone but also increases
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/diabetes-1.pdf
March 01, 2020 - residents have diabetes, contributing to increases in the number of inpatients with multiple chronic
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/alcohol-misuse_executive.pdf
April 28, 2010 - If only half of all those with a positive screening test receive an intervention, then the NNS range increases … If 90% of
those with a positive screen receive an intervention, the NNS range increases to 35 to 253 … sensitivity is 81% and only half
of those with a positive screen receive an intervention, then the NNS range increases
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/Wezro6zTSfAWxCrneF-nxB
May 01, 2005 - As the prevalence of gonorrhea
increases, the NNS to prevent cases of gonorrhea and PID decrease accordingly … Increases in fluoroquinolone-resistant Neisseria
gonorrhoeae among men who have sex with men--
United … Increases in gonorrhea and sexual risk
behaviors among men who have sex with men: a
12-year trend analysis … Increases in unsafe sex and rectal gonorrhea among
men who have sex with men--San Francisco,
California