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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49493/psn-pdf
    November 01, 2005 - Infused, Not Ingested November 1, 2005 Foley M. Infused, Not Ingested. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/infused-not-ingested The Case A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering contrast, an unfamiliar task for this particular nurse. Rathe…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49517/psn-pdf
    August 01, 2006 - Miscalculated Risk August 1, 2006 Strassels SA. Miscalculated Risk. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/miscalculated-risk The Case A healthy 36-year-old man was admitted to a teaching hospital for acute low back strain after lifting his 2- week-old infant. He received Vicodin (hydrocodone and a…
  3. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
    January 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case January 2008 How Do Providers Recover from Errors? Source and Credits This presentation is based on the January 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Colin P. West, MD, PhD, Mayo Clini…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49397/psn-pdf
    May 01, 2003 - The Dropped Lung May 1, 2003 Heffner JR. The Dropped Lung. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dropped-lung The Case A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33650/psn-pdf
    May 01, 2007 - Patient Safety in the United Kingdom: Evolution and Progress May 1, 2007 Burnett S, Vincent CA. Patient Safety in the United Kingdom: Evolution and Progress. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress Perspective The dangers of health care in B…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33682/psn-pdf
    April 01, 2009 - In Conversation with...Mark Chassin, MD, MPP, MPH April 1, 2009 In Conversation with..Mark Chassin, MD, MPP, MPH . PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph Editor's note: Mark R. Chassin, MD, MPP, MPH, is president of The Joint Commission, the preeminent s…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50842/psn-pdf
    January 29, 2020 - Patient Identification Errors: A Systems Challenge January 29, 2020 Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge The Cases The following four events involving five patients all involved…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72587/psn-pdf
    December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability December 23, 2020 Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851158/psn-pdf
    June 28, 2023 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization June 28, 2023 Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization The Case A patient was …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49776/psn-pdf
    November 01, 2016 - Continuity Errors in Resident Clinic November 1, 2016 Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic The Case A 32-year-old woman presented to internal medicine clinic for evaluation of headaches and difficulty concentrating. …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73515/psn-pdf
    August 01, 2022 - Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents July 28, 2021 https://psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing- home-residents Summary The MOQI seeks to reduce avoidable hospitalization among nursing home residents b…
  12. www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreen5.html
    April 01, 2018 - Health Care Systems for Tracking Colorectal Cancer Screening Tests 5. Dissemination Previous Page Next Page Table of Contents Health Care Systems for Tracking Colorectal Cancer Screening Tests Executive Summary 1. Introduction 2. Description of the Intervention 2. Description of the Interven…
  13. www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/operational-adjustments-event-summary.pdf
    July 02, 2020 - 1 Learning Community Affinity Group Summary-at-a-Glance: Operational Adjustments while Resuming In-Person Cardiac Rehabilitation Programs July 2, 2020 Event Purpose and Overview • Purpose: To share and acquire strategies for how to adjust operations while resuming in-person cardiac rehabilitation p…
  14. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.docx
    May 01, 2017 - AHRQ Safety Program for Perinatal Care Monitoring for Perinatal Safety: Electronic Fetal Monitoring Monitoring for Perinatal Safety—Electronic Fetal Monitoring SAY: The Monitoring for Perinatal Safety bundle provides information on the use of electronic fetal monitoring (EFM). This bundle offers an approach to the us…
  15. www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-fac-guide.html
    July 01, 2023 - Monitoring for Perinatal Safety: Electronic Fetal Monitoring: Facilitator Guide AHRQ Safety Program for Perinatal Care Slide 1: Monitoring for Perinatal Safety: Electronic Fetal Monitoring Say: The Monitoring for Perinatal Safety bundle provides information on the use of electronic fetal monitoring (EFM…
  16. www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-cord-prolapse.html
    July 01, 2023 - Labor and Delivery Unit Safety: Umbilical Cord Prolapse AHRQ Safety Program for Perinatal Care Purpose of the tool: This tool describes the key perinatal safety elements that support safe umbilical cord prolapse management. The key safety elements are presented within the framework of the Compreh…
  17. www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/osteoporosis-screening
    November 18, 2021 - Share to Facebook Share to X Share to WhatsApp Share to Email Print Final Research Plan Osteoporosis to Prevent Fractures: Screening November 18, 2021 Recommendations made by the USPSTF are independent of the U.S. government. They should not b…
  18. psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
    April 28, 2021 - Procedural Mishap: Learning Curve? Citation Text: Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…
  19. digital.ahrq.gov/ahrq-funded-projects/patient-centered-outcomes-research-clinical-decision-support-current-state-and
    January 01, 2024 - Patient-Centered Outcomes Research Clinical Decision Support: Current State and Future Directions Project Description Publications Research Story Trust, interoperability, and ease of implementation are important factors that can increase uptake of evidence into prac…
  20. integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/challenging-patient-behaviors-and-concerns
    January 01, 2021 - An official website of the Department of Health & Human Services Search All AHRQ Sites Careers Contact Us Español FAQs Email Updates The Academy Integrating Behavioral Health & Primary Care Expand Navi…