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9101. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72516/psn-pdf
      November 25, 2020 - Premature Closure: Was It Just Syncope? November 25, 2020 Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…

9102. Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
      January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx Spotlight Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes Source and Credits • This presentation is based on the April 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/we…

9103. Spotlight: Mistaken Attribution, Diagnostic Misstep | PSNet
      psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
      July 01, 2011 - SPOTLIGHT CASE Spotlight: Mistaken Attribution, Diagnostic Misstep Citation Text: Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citat…

9104. Mobility Lost in the ICU | PSNet
      psnet.ahrq.gov/web-mm/mobility-lost-icu
      August 01, 2018 - SPOTLIGHT CASE Mobility Lost in the ICU Citation Text: Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…

9105. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851389/psn-pdf
      July 31, 2023 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023 https://psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer Summary Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, a…

9106. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60268/psn-pdf
      April 29, 2020 - Complications of ECMO During Transport April 29, 2020 Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport The Case A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with acute on chro…

9107. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73102/psn-pdf
      July 01, 2022 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use March 31, 2021 https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail- community-dwelling Summary Care management staff (such …

9108. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73128/psn-pdf
      July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients. April 7, 2021 https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications- and-enhances Summary The Hospital at Homesm program provides hospital-level care…

9109. Spreading Lean: Taking Efficiency Interventions in Health Services Delivery to Scale - Executive Summary (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/execsumm-lean-redesign.pdf
      March 01, 2017 - Spreading Lean: Taking Efficiency Interventions in Health Services Delivery to Scale - Executive Summary Executive Summary Spreading Lean: Taking Efficiency Interventions in Health Services Delivery to Scale Prepared for: Agency for Healthcare Research and Quality 5600 Fishers Lane …

9110. On-Time Pressure Ulcer Healing: Facilitator Training Instructor's Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/facguide.html
      December 01, 2017 - On-Time Pressure Ulcer Healing: Facilitator Training Instructor's Guide AHRQ’s Safety Program for Nursing Homes: Implementation of the Healing Reports Note: This part of the training primarily consists of exercises and does not have any associated slides. Review of Self-Assessment Worksheet Say:   Y…

9111. Implement Teamwork and Communication for Perinatal Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.pdf
      May 01, 2017 - Implement Teamwork and Communication for Perinatal Safety AHRQ Safety Program for Perinatal Care Implement Teamwork and Communication for Perinatal Safety AHRQ Publication No. 17-0003-3-EF May 2017 SAY: The Implement Teamwork and Communication module of the AHRQ Safety Program for Perinatal Care will help yo…

9112. 4. How Do We Implement Best Practices in Our Organization? (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu4a.html
      October 01, 2014 - Preventing Pressure Ulcers in Hospitals 4. How Do We Implement Best Practices in Our Organization? (continued) Previous Page Next Page Table of Contents Preventing Pressure Ulcers in Hospitals Overview Key Subject Area Index 1. Are we ready for this change? 2. How will we manage change? 3.…

9113. Background Report for the Request for Public Comment on Initial, Recommended Core Set of Children's Healthcare Quality Measures for Voluntary Use by Medicaid and CHIP Programs | Agency for Healthcare Research and Quality
      www.ahrq.gov/policymakers/chipra/overview/background/methods.html
      December 01, 2009 - Background Report for the Request for Public Comment on Initial, Recommended Core Set of Children's Healthcare Quality Measures for Voluntary Use by Medicaid and CHIP Programs Background Report on request for public comment on initial, recommended core set of Children's Healthcare Quality Measures for voluntary…

9114. Final Progress Report: Immersive Simulation for Design and Evaluation of an Emergency Department IT System (pdf file)
      www.ahrq.gov/sites/default/files/2025-05/bisantz-report.pdf
      January 01, 2025 - Final Progress Report: Immersive Simulation for Design and Evaluation of an Emergency Department IT System Immersive Simulation for Design and Evaluation of an Emergency Department IT System Principal Investigator: Ann Bisantz, PhD1 Co-Investigators: Rollin J. Terry Fairbanks, MD1, 2,5 Li Lin, PhD1 A. Zachary He…

9115. 4. How Do We Implement Best Practices in Our Organization? (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu4a.html
      October 01, 2014 - Preventing Pressure Ulcers in Hospitals 4. How Do We Implement Best Practices in Our Organization? (continued) Previous Page Next Page Table of Contents Preventing Pressure Ulcers in Hospitals Overview Key Subject Area Index 1. Are we ready for this change? 2. How will we manage change? 3.…

9116. Teamworknotes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/implement/teamworknotes.docx
      June 02, 2025 - SAY: The “Implement Teamwork and Communication” module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit will help you understand the importance of effective communication and transparency, identify barriers to communication, and apply the effective teamwork and communication tools from CUSP and TeamSTEP…

9117. Assembleteam (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/assemble/assembleteam.docx
      June 02, 2025 - SAY: The “Assemble the Team” module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit addresses CUSP team composition for your quality improvement initiative. This module will help you understand five concepts: the importance of teamwork and team composition to the CUSP initiative, developing a strategy …

9118. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49849/psn-pdf
      January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep January 1, 2019 Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep Case Objectives List the patient safety events that are unique to in…

9119. Slide 1 (ppt file)
      effectivehealthcare.ahrq.gov/sites/default/files/module_i1.ppt
      October 08, 2025 - Slide 1 Engaging Stakeholders in the Effective Health Care Program Information and tools for researchers and investigators Numeric

9120. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. | PSNet
      psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
      November 30, 2021 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. Citation Text: Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …