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psnet.ahrq.gov/web-mm/multiple-missed-opportunities-suicide-risk-assessment-emergency-and-primary-care-settings
May 26, 2021 - recommend any one tool, 11 several mentioned by the Joint Commission and the national Zero Suicide initiative
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psnet.ahrq.gov/perspective/diagnostic-errors
December 01, 2013 - Let's say you weren't fundamentally interested in IT-related safety issues, but you see a huge federal initiative
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/bladder-cancer-adults-screening-1996
January 01, 1996 - Share to Facebook
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archived
Final Recommendation Statement
Bladder Cancer in Adults: Screening, 1996
January 01, 1996
Recommendations made by the USPSTF are independent of the U.S. governme…
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psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
October 01, 2017 - Preventing PICC Complications: Whose Line Is It?
Citation Text:
Moureau N. Preventing PICC Complications: Whose Line Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Google Scholar BibT…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/assessment.html
December 01, 2017 - On-Time Pressure Ulcer Assessment
AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing
The On-Time Pressure Ulcer Assessment incorporates elements from the Bates-Jensen Wound Assessment Tool (BWAT) with additional standardized treatment and intervention descriptors. The On-Time Pressur…
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psnet.ahrq.gov/node/841469/psn-pdf
December 14, 2022 - Strongyloides: A Hidden Traveler and Potentially Lethal
Missed Diagnosis.
December 14, 2022
Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed
Diagnosis. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-mi…
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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - Failure to Latch
September 1, 2008
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/failure-latch
The Case
The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to
breastfeeding exclusively for 6 months. However, early br…
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psnet.ahrq.gov/web-mm/chemotherapy-extravasation
September 24, 2010 - Chemotherapy Extravasation
Citation Text:
Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
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psnet.ahrq.gov/node/49411/psn-pdf
July 01, 2003 - Code Status Confusion
July 1, 2003
Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/code-status-confusion
Case Objectives
Appreciate challenges of determining goals of care in hospitalized patients
Understand patients’ common misconceptions about CPR
List typical mist…
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psnet.ahrq.gov/node/60952/psn-pdf
September 30, 2020 - When the Lytes Go Out: A Case of Inpatient Cardiac
Arrest
September 30, 2020
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
Disclosure of Relevant Financial Relationships: As a pr…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.docx
June 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing
On-Time Pressure Ulcer Assessment
The On-Time Pressure Ulcer Assessment incorporates elements from the Bates-Jensen Wound Assessment Tool (BWAT) with additional standardized treatment and intervention descriptors. The On-Time Pressure Ulcer Assess…
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psnet.ahrq.gov/node/49440/psn-pdf
March 01, 2004 - Autopsy Revelation
March 1, 2004
Shojania KG. Autopsy Revelation. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/autopsy-revelation
The Case
A 45-year-old male with development delay presented to the emergency department with acute abdominal
pain. His mother, who was his main caregiver, accompanied him. Th…
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psnet.ahrq.gov/node/865984/psn-pdf
May 29, 2024 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain
with Elevated D-dimer.
May 29, 2024
Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-
dimer. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-d…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
May 01, 2017 - Engage Patients and Families for Perinatal Safety
AHRQ Safety Program for Perinatal Care
Engage Patients and Families for Perinatal Safety
AHRQ Publication No. 17-0003-6-EF
May 2017
SAY:
The Patient and Family Engagement module
focuses on an important topic: making sure
patients and their family members un…
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/involving-patients-families-in-safety-slides.pdf
July 25, 2023 - Involving Patients and Families in Safety: Slide Presentation
The National Action Alliance to Advance Patient
Safety Summer Webinar Series
Involving Patients and Families in Safety
July 25, 2023
2:00-3:00 PM ET
Special Guest Speakers
Sue Sheridan,
MIM, MBA, DHL
Founding Member,
Patients For Patient
Safety U…
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www.ahrq.gov/hai/tools/mvp/modules/technical/4es-early-mobility-facguide.html
February 01, 2017 - The Four Es of Early Mobility: Facilitator Guide
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: The Four Es of Early Mobility
Say:
This module explains how to apply the Four Es of the TRIP framework to Early Mobility: engage, educate, execute, and evaluate.
Slide 2: Learning Objecti…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
May 01, 2017 - PowerPoint Presentation
Spotlight
Diagnostic Delay in the Emergency Department
1
Source and Credits
This presentation is based on the May 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Kyle Marshall, MD, Geisinger Medical Center, Danv…
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psnet.ahrq.gov/node/60044/psn-pdf
March 16, 2020 - Patient Safety in Medical, Nursing, and Other Clinical
Education
March 16, 2020
Howley LD, Hall KK, Fitall E. Patient Safety in Medical, Nursing, and Other Clinical Education . PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/patient-safety-medical-nursing-and-other-clinical-education
Background
Despit…
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psnet.ahrq.gov/web-mm/ectopic-or-not
March 27, 2024 - Ectopic or Not?
Citation Text:
Givens VM, Lipscomb GH. Ectopic or Not?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/index.html
October 01, 2020 - What We Learned
The CHIPRA quality demonstration States are pursuing innovative strategies to improve health care for children.
Learn about the CHIPRA quality demonstration States' strategies, lessons learned, and outcomes from these National Evaluation products:
Final Summary
Final Project Report
Spe…