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  1. Miscommunication in the OR Leads to Anticoagulation Mishap | PSNet

    psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
    May 08, 2019 - Miscommunication in the OR Leads to Anticoagulation Mishap Citation Text: Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Forma…

  2. An Easily Forgotten Tube | PSNet

    psnet.ahrq.gov/web-mm/easily-forgotten-tube
    June 01, 2016 - An Easily Forgotten Tube Citation Text: Ousey K. An Easily Forgotten Tube. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…

  3. Preventable Emergency Department Visits | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure2.html
    June 01, 2018 - Chartbook on Care Coordination Preventable Emergency Department Visits Previous Page Next Page Table of Contents Chartbook on Care Coordination Acknowledgments Care Coordination Trends in Care Coordination Measures Transitions of Care Preventable Emergency Department Visits Potentially A…

  4. Section 2: Explanation and Value of the TeamSTEPPS Curriculum  | Agency for Healthcare Research and Quality

    www.ahrq.gov/teamstepps-program/curriculum/intro/explain.html
    July 01, 2023 - Section 2: Explanation and Value of the TeamSTEPPS Curriculum  This section contains explanations and illustrations to help you better understand and appreciate the structure and importance of the TeamSTEPPS curriculum and its key concepts. If you teach this content or want additional insights into how the mate…

  5. Improving Hospital Handoffs Using AHRQ’s Surveys on Patient Safety Culture® Hospital Survey - Hansford and Murray (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-sops-riverside-handoffs-webcast-hansford.pdf
    January 01, 2023 - Improving Hospital Handoffs Using AHRQ’s Surveys on Patient Safety Culture® Hospital Survey - Hansford and Murray Assessing Patient Safety Culture to Improve Hospital Handoffs Ashley Hansford, BS, CPPS Patient Safety Manager Lauren Murray, MSN, RN, CMSRN Director of Nursing, Med/Surg Unit Riverside Health Sys…

  6. Facapplycusp (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/facapplycusp.docx
    June 02, 2025 - SAY: The “Apply CUSP” module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit introduces Just Culture principles, which emphasize shared accountability and attitudes toward risk. This module also summarizes the concepts and activities of the other six modules in the CUSP Toolkit. Slide 1 SAY: In th…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33739/psn-pdf
    October 01, 2012 - The Physical Environment: An Often Unconsidered Patient Safety Tool October 1, 2012 Joseph A, Malone EB. The Physical Environment: An Often Unconsidered Patient Safety Tool. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool Perspective Now that…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49710/psn-pdf
    May 01, 2014 - Discontinued Medications: Are They Really Discontinued? May 1, 2014 Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued? PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued The Case A 69-year-old man with a history of chronic atrial f…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73335/psn-pdf
    May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition Error May 26, 2021 Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error The Case A 4-year-old (former 33-week premature) boy with a …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49670/psn-pdf
    November 01, 2012 - Missed Pneumonia November 1, 2012 Rohde JM, Flanders S. Missed Pneumonia. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/missed-pneumonia The Case A 32-year-old man presented to the emergency department (ED) with 3 days of fever and right pleuritic chest pain. Review of systems was negative for cough or dy…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33884/psn-pdf
    July 01, 2019 - Emerging Safety Issues in Artificial Intelligence July 1, 2019 Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence Perspective Background Since the beginning of digital health records, there has bee…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33845/psn-pdf
    November 01, 2017 - In Conversation With… Wanda Pratt, PhD November 1, 2017 In Conversation With… Wanda Pratt, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd Editor's note: Wanda Pratt is a Professor in the Information School with an adjunct appointment in the Division of Biomedical and …

  13. Facilitator Guide for Hospital AIM Team Leads (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/sppcii-facilitator-guide.docx
    July 01, 2023 - Facilitator Guide for Hospital AIM Team Leads Facilitator Guide for Hospital AIM Team Leads What Is This Guide? This guide is intended as a complement to the online training modules of the Safety Program for Perinatal Care II (SPPC-II) Teamwork Toolkit. It provides helpful information about scheduling and conducting …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33673/psn-pdf
    September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety September 1, 2008 Rothschild JM, Keohane C. The Role of Bar Coding and Smart Pumps in Safety. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety Perspective Medication safety in hospitals depends on the successful execu…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49538/psn-pdf
    June 01, 2007 - Abnormal Volunteer Results June 1, 2007 Fernandez C. Abnormal Volunteer Results. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/abnormal-volunteer-results The Case A healthy 52-year-old woman volunteered to participate in a radiology study in which she underwent magnetic resonance imaging (MRI) of her abdo…

  16. Chapter 6. Measure Maps and Profiles (continued, 12) | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6k.html
    June 01, 2014 - Care Coordination Measures Atlas Update Chapter 6. Measure Maps and Profiles (continued, 12) Previous Page Next Page Table of Contents Care Coordination Measures Atlas Update Chapter 1: Background Chapter 2. What is Care Coordination? Chapter 3. Care Coordination Measurement Framework Chapte…

  17. Facilitator-Notes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module1/facilitator-notes.docx
    March 01, 2017 - Facilitator Notes SAY: The Comprehensive LTC Safety Modules assist users with how to apply safety principles. This overview module explains the purpose of the toolkit and how it can be used in your facility’s quality improvement initiatives. SLIDE 1 SAY: The objectives of this module are to— · Describe the purpo…

  18. Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles: Facilitator Notes | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-facguide.html
    March 01, 2017 - Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles: Facilitator Notes AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Slide 1: Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles Say: The Comprehensive LTC Safety Modules…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33786/psn-pdf
    May 01, 2015 - Video to Improve Patient Safety: Clinical and Educational Uses May 1, 2015 Xiao Y, Mackenzie CF, Seagull JF. Video to Improve Patient Safety: Clinical and Educational Uses. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses Perspective Reports of…

  20. 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…
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