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psnet.ahrq.gov/node/49739/psn-pdf
August 21, 2015 - Breathe Easy: Safe Tracheostomy Management
August 21, 2015
Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
The Case
A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumo…
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psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
August 06, 2014 - Delayed Clozapine Prescription in an Elderly Man With Dementia
Citation Text:
Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/podcasts/Tackling_Low_Health_Literacy_Among_PCP_2012_05_01_Transcript.pdf
January 01, 2012 - Tackling Low Health Literacy Among Primary Care Patients: A Model from Missouri
Tackling Low Health Literacy Among Primary Care Patients: A Model from Missouri
May 2012 Podcast
Speaker
Stan Hudson, Associate Director, Center for Health Policy, University of Missouri; Chairman, Health Literacy
Education …
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www.ahrq.gov/research/publications/pubcomguide/pcguide1a.html
March 01, 2025 - Publishing and Communications Guidelines
Section 1: Product Development (continued)
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Table of Contents
Publishing and Communications Guidelines
Section 1: Product Development
Audio and Video Products
Appendix 1-A. Release Forms
Appendix 1-B. Trademarks
Appendix 1-C. …
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psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
August 10, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Diagnostic Errors Case Studies
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Created By: Maria Mirica, PRIDE Group
…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/podcasts/CreatinganEffectiveCustomerServiceTrainingProgram20120501Transcript52312.pdf
May 01, 2012 - Creating an Effective Customer Service Training Program
Creating an Effective Customer Service Program
May 2012 Podcast
Speaker
Lisa Sergy, Assistant Director at UCLA’s Health System in the Faculty Practice Group
Moderator
Carla Zema, Consultant, CAHPS User Network; Assistant Professor of Economics and…
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psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
February 01, 2019 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room
Citation Text:
Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. Rockville (MD): Agency for H…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/110-ss-lfd-sample.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Learning From Defects Tool—Sample
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
What Is a Defect?
A defect is any clinical or operational event or situation that you would not want to happen again. This could include i…
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www.ahrq.gov/patient-safety/reports/hotline/implement3.html
May 01, 2016 - Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events
III. Hotline Implementation and Refinement
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Table of Contents
Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for…
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psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
November 01, 2008 - In Conversation with…Sanjay Saint, MD, MPH
November 1, 2008
Also Read an Essay
Citation Text:
In Conversation with…Sanjay Saint, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 200…
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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - A Stroke of Error
December 1, 2014
Barrett KM. A Stroke of Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/stroke-error
Case Objectives
State the key clinical factors to assess in a patient with suspected stroke.
Appreciate the relationship between elevated blood pressure and stroke in the acute sett…
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psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
November 01, 2008 - Health Care–Acquired Urinary Tract Infection: The Problem and Solutions
Lindsay E. Nicolle, MD | November 1, 2008
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Nicolle LE. Health Care–Acquired Urinary Tract Infection: The Pr…
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psnet.ahrq.gov/node/84413/psn-pdf
February 23, 2022 - A Loss of Trust and a Missed Diagnosis
February 23, 2022
Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counci…
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psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-and-enhances
November 15, 2023 - Hospital at Home℠ Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients.
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April 7, 2021
Innovation…
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www.ahrq.gov/hai/cauti-tools/archived-webinars/cauti-sustainability-slides.html
December 01, 2017 - CAUTI Sustainability: Embedding CAUTI Policies, Using Data to Monitor Proress and Hardwiring CUSP Principles
Slide Presentation
Slide 1
CAUTI Sustainability: Embedding CAUTI Policies, Using Data to Monitor Progress and Hardwiring CUSP Principles
Diane Byrum, RN, MSN, CCRN, CCNS, FCCM
Manager, Quality I…
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/healthy-diet-and-physical-activity-counseling-for-cvd-prevention-in-adults-2012
June 15, 2012 - Share to Facebook
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archived
Final Recommendation Statement
Healthy Diet and Physical Activity: Counseling for CVD Prevention in Adults
June 15, 2012
Recommendations made by the USPSTF …
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www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-measures-atlas/ccrm-atlasapd3.html
March 01, 2013 - Clinical-Community Relationships Measures (CCRM) Atlas
Wrap-Around Observation Manual—Second Version
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Table of Contents
Clinical-Community Relationships Measures (CCRM) Atlas
Introduction
Acknowledgments
1. Why Was the Clinical-Community Relationships Measures Atlas Deve…
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www.ahrq.gov/cahps/quality-improvement/research/index.html
March 01, 2025 - Research on Improving Patient Experience
Many researchers study the feasibility and value of using CAHPS surveys to support efforts to improve patient experience in various healthcare settings. This page summarizes current and recent research funded under AHRQ’s CAHPS grants related to: Improving patient experi…
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psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
September 27, 2023 - SPOTLIGHT CASE
Missed Opportunities for Suicide Risk Assessment
Citation Text:
Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/867035/psn-pdf
October 30, 2024 - A Tale of Two Falls
October 30, 2024
Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/tale-two-falls
The Cases
Case #1: A 79-year-old woman with a history of impaired cognition at baseline was brought from a skilled
nursing facility to the emergency department (ED) f…