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psnet.ahrq.gov/node/49521/psn-pdf
September 12, 2006 - A Troubling Amine
September 1, 2006
Flynn EA. A Troubling Amine. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/troubling-amine
The Case
A 43-year-old woman was admitted to the intensive care unit for symptoms of heart and respiratory failure.
She was found to have severe mitral and tricuspid valve regurgi…
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cds.ahrq.gov/sites/default/files/workgroups/33746/CDS_Connect_WG_Summary_September_2021.pdf
January 01, 2021 - September 2021 CDS Connect Work Group Meeting Summary
Clinical Decision Support (CDS) Connect Work Group (WG)
Meeting Summary
September 16, 2021
3:00-4:00 pm ET
Attendees: 33 people, including 4 phone dial-ins
Organization Attendees
AHRQ Sponsors Roland Gamache, Edward Lomotan, Mario Teran (3)
WG M…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/Ways_To_Learn_More_508.docx
June 02, 2025 - Information to Help Hospitals Get Started
Ways to Learn More
Information to Help Hospitals Get Started
[Type text] [Type text] [Type text]
Information to Help Hospitals Get Started
Guide to Patient and Family Engagement :: 1
Guide to Patient and Family Engagement :: 2
This document contains links to resources on t…
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www.ahrq.gov/research/shuttered/toolkitchecklist/surgetkit1.html
July 01, 2018 - How to Use This Toolkit
Public Health Emergency Preparedness
Reopening a closed ("shuttered") hospital to expand surge capacity in an emergency requires significant planning. This Toolkit is a step-by-step guide to assist staff responsible for management, legal, facility, staffing, security, materials managem…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_4_PPT_508.pdf
June 02, 2025 - Strategy 4: IDEA Discharge Planning (Tool 4)
Guide to Patient & Family Engagement
Insert hospital logo here
Care Transitions from Hospital to
Home: IDEAL Discharge Planning
Training
[Hospital Name | Presenter name and title | Date of presentation]
Strategy 4: IDEAL Discharge Planning (Tool 4)
Today…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/improving-communication-guide.docx
September 01, 2022 - Improving Communication Between Members of the Practice Around Antibiotic Decisions – Facilitator Guide
AHRQ Safety Program for Improving Antibiotic Use
1
Improving Communication Between Members of the Practice Around Antibiotic Decisions
Ambulatory Care
Slide Title and Commentary
Slide Number and Slide
Im…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/sustainability/guide.html
March 01, 2017 - Guide to Sustaining a Program To Reduce Catheter-Associated Urinary Tract Infections in Long-Term Care
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Contents
Overview
How To Use This Guide
LTC Safety Toolkit Modules
Sustainability Essentials
Leadership Commitment
…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/leveraging-cultural-change-080814.pptx
January 01, 2013 - Slide 1
Leveraging Cultural Change to Reduce Urinary Catheter Use
1
Linda Greene, RN,MPS,CIC
Manager Infection Prevention
Highland Hospital
Jennifer Tuttle, RN, MSNEd
Adult Critical Care Unit
Tucson Medical Center
Learning Objectives
Describe the way in which improvement in the clinical culture can facilitate e…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Learning From Defects: Applying the “Swiss cheese model” of System Failure
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
Slide Title and Commentary
Slide Number and Slide
Learning From Defects: Applying the “Swiss C…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module7/module7-resolution-facilitator.pptx
August 24, 2015 - PowerPoint Presentation
Communication and Optimal Resolution
(CANDOR)
Toolkit
Module 7: Resolution
Module 7 of the CANDOR Toolkit describes the resolution phase of the CANDOR process.
1
Objectives
Define the CANDOR Resolution component and its importance in the CANDOR process.
List the steps of the resolution pr…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_sustspreading.pptx
December 01, 2017 - Presentation: Sustaining and Spreading Surgical Improvments
Sustaining and Spreading Surgical Safety Improvements
AHRQ Safety Program for Surgery
Sustainability
AHRQ Pub. No. 16(18)-0004-15-EF
December 2017
AHRQ Safety Program for Surgery – Sustainability
SAY:
This module will cover Sustaining and Spreading Surgic…
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psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - Diffusion of Responsibility Leads to Danger
October 1, 2018
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
The Case
A 70-year-old man was sent to the emergency department (ED) from a nursing facility…
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psnet.ahrq.gov/node/49724/psn-pdf
January 01, 2015 - Bowel Injury After Laparoscopic Surgery
January 1, 2015
Moorthy K. Bowel Injury After Laparoscopic Surgery. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery
The Case
A 30-year-old man presented to the hospital for a scheduled laparoscopic inguinal hernia repair with mes…
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psnet.ahrq.gov/node/49756/psn-pdf
April 01, 2016 - Lost in Sign Out and Documentation
April 1, 2016
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
The Case
A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the
emergency physician, …
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psnet.ahrq.gov/node/865570/psn-pdf
April 10, 2024 - Risk Mitigation Using the Anesthesia Risk Alert Program:
Applying a Proactive Approach With Data Review &
Collaborating With a Second Practitioner
April 10, 2024
https://psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-
approach-data
Summary
North American Partners…
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psnet.ahrq.gov/node/865467/psn-pdf
March 27, 2024 - I Just Want to Go Home: Understanding Delirium’s Impact
on Treatment Preferences
March 27, 2024
Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferenc…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/primary-research-design_research.pdf
January 01, 2012 - Involving a statistician to consider applying these methods may be appropriate. 27-29
3.
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/rtc-design-principles_research.pdf
January 01, 2009 - A diagnostic strategy involving a
quantitative latex D-dimer assay
reliably excludes deep venous
thrombosis
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www.ahrq.gov/sites/default/files/publications2/files/distributed-cognition-er-nurses_0.pdf
August 01, 2022 - a system.17 It is one of a family of social cognitive theories known as situativity
theory,18 all involving
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
August 01, 2022 - a system.17 It is one of a family of social cognitive theories known as situativity
theory,18 all involving