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psnet.ahrq.gov/node/847934/psn-pdf
April 26, 2023 - Patient Safety Indicators
April 26, 2023
Tokareva I, Romano P. Patient Safety Indicators. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/patient-safety-indicators
Background
Over the past 25 years, policymakers and providers, payers, and purchasers of health care have
increasingly focused attention on pati…
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psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
August 15, 2017 - Perils in Diagnosing a Stroke
Citation Text:
Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
November 01, 2003 - CVC Placement: Speak Now or Do Not Use the Line
Citation Text:
Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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digital.ahrq.gov/sites/default/files/docs/page/A_ReferenceLibrary_1.pdf
February 16, 2006 - A_ReferenceLibrary
Appendix A:
Reference Library
APPENDIX A: REFERENCE LIBRARY
PURPOSE: This reference library is intended to provide a focused subset of key papers,
presentations, and other resources to aid readers in understanding the critical issues
underlying the purpose of the Privacy and Securit…
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psnet.ahrq.gov/web-mm/too-tight-control
March 20, 2013 - SPOTLIGHT CASE
Too Tight Control
Citation Text:
Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/33809/psn-pdf
June 01, 2016 - In Conversation With… Gregg S. Meyer, MD, MSc
June 1, 2016
In Conversation With… Gregg S. Meyer, MD, MSc. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc
Editor's note: Dr. Meyer is Chief Clinical Officer of Partners Healthcare System, the large Boston-based
system tha…
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psnet.ahrq.gov/node/49779/psn-pdf
January 01, 2017 - The Empty Bag
December 1, 2016
Vincent C. The Empty Bag. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/empty-bag
The Case
A 90-year-old woman with end-stage dementia was admitted to an acute care hospital for treatment of a
hip fracture after a fall at a nursing home. During the hospitalization, her kidne…
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psnet.ahrq.gov/node/49639/psn-pdf
November 01, 2011 - Near Miss with Bedside Medications
November 1, 2011
Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications
Case Objectives
Understanding the definition of near miss—also known as close call.
Appreciate the importance of close calls in reducin…
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psnet.ahrq.gov/node/33668/psn-pdf
May 01, 2008 - In Conversation with…David W. Bates, MD, MSc
May 1, 2008
In Conversation with…David W. Bates, MD, MSc. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
Editor's note: Dr. David Bates is a Professor at Harvard Medical School, Medical Director of Clinical and
Quality …
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psnet.ahrq.gov/node/33746/psn-pdf
March 01, 2013 - In Conversation With… David M. Gaba, MD
March 1, 2013
In Conversation With… David M. Gaba, MD. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
Editor's note: David M. Gaba, MD, is a Professor of Anesthesia at the Stanford University School of
Medicine. An international leade…
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psnet.ahrq.gov/node/49654/psn-pdf
June 01, 2012 - Transfer Troubles
June 1, 2012
Hains IM. Transfer Troubles. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfer-troubles
Case Objectives
Recognize that transfer of patients between hospitals is common.
Understand the frequency of errors and adverse events in the transfer of patients between hospitals.
…
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psnet.ahrq.gov/node/49678/psn-pdf
March 01, 2013 - A Weighty Mistake
March 1, 2013
Bokser SJ. A Weighty Mistake. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/weighty-mistake
Case Objectives
Understand factors associated with weight-based dosing medication errors in pediatric populations.
Describe how adoption of computerized provider order entry (CPOE) s…
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psnet.ahrq.gov/node/49760/psn-pdf
May 01, 2016 - Mismanagement of Delirium
May 1, 2016
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/mismanagement-delirium
The Case
An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although
fitted with a cast at a regional ho…
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psnet.ahrq.gov/node/49698/psn-pdf
December 01, 2013 - SNFs: Opening the Black Box
December 1, 2013
Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/snfs-opening-black-box
The Case
An 88-year-old woman was admitted to a skilled nursing facility (SNF) after a lengthy hospitalization for a
small bowel obstructio…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/prostate-cancer-surveillance_research-protocol.pdf
May 19, 2011 - Evidence-based Practice Center Review Protocol
Source: www.effectivehealthcare.ahrq.gov
Published Online: May 19, 2011
Evidence-based Practice Center Review Protocol
NIH State-of-the-Science Conference:
Role of Active Surveillance in the Management of Men With Localized Prostate Cancer
I. Backg…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-200-section-8-data-feasibility-tool-1.pdf
June 02, 2025 - Section 8, Data Feasibility Tool and Feasibility Testing Results
EHR Data Feasibility Tool copyright 2011 American Medical
Association. All Rights Reserved. This tool and the information
contained therein may not be reproduced or distributed and may
only be used for collecting data in connection with an agreement…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-199-section-8-a-ehr-data-feasibility-tool.pdf
June 02, 2025 - Section 8-A, EHR Data Feasibility Tool
EHR Data Feasibility Tool copyright 2011 American Medical
Association. All Rights Reserved. This tool and the information
contained therein may not be reproduced or distributed and may
only be used for collecting data in connection with an agreement
with the American Medica…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemedication.pptx
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Safe Medication Administration
AHRQ Safety Program for Perinatal Care
Safe Medication Administration
AHRQ Publication No. 17-0003-19-EF
May 2017
1
Learning Objectives
2
AHRQ Safety Program for Perinatal Care
Safe Med. Admin.
2
Safe Administration of Medications in L&D
T…
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digital.ahrq.gov/ahrq-funded-projects/optimizing-value-patient-reported-outcome-measures-improving-care-delivery
January 01, 2024 - Optimizing the Value of Patient-Reported Outcome Measures in Improving Care Delivery through Health Information Technology
Project Final Report ( PDF , 473.77 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible f…
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psnet.ahrq.gov/web-mm/its-sarah-not-stephen
January 01, 2015 - SPOTLIGHT CASE
It's Sarah, Not Stephen!
Citation Text:
Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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