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psnet.ahrq.gov/web-mm/customer-always-right
January 22, 2014 - SPOTLIGHT CASE
The "Customer" Is Always Right
Citation Text:
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Tacit Handover, Overt Mishap
Citation Text:
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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www.ahrq.gov/sites/default/files/wysiwyg/stepup_Challenge/step-up-challenge-phase-1-webinar-slides.pdf
September 24, 2018 - AHRQ Step Up App Challenge Phase 1 Informational Webinar
AHRQ Step Up App Challenge
Advancing Care Through Patient Self-Assessments
Phase 1 Informational Webinar
Learn about the challenge and how to enter Phase 1
For more information, visit:
www.ahrq.gov/stepupappchallenge 1
http…
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psnet.ahrq.gov/web-mm/who-nose-where-airway
May 01, 2016 - Who Nose Where the Airway Is?
Citation Text:
Lee CR. Who Nose Where the Airway Is?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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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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digital.ahrq.gov/sites/default/files/docs/page/UHIN_BusinessCaseReport.pdf
November 01, 2005 - Establishing a Business Case for Health Information Exchange (HIE)
…
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effectivehealthcare.ahrq.gov/sites/default/files/frazee-presentation.pdf
May 29, 2025 - Frazee-notes-151006 copy - Teresa
So thank you very much.
I'm taking a little bit
of a different
tactic on this, but
I want
to say
I'm in
agreement with
both
Dr. Hibbard
and
Dr. Fagerlin.
I think we just
take different
approaches to the same information, which is what makes t…
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs018183-weiner-final-report-2013.pdf
January 01, 2013 - Medication Reconciliation Technology to Improve Quality of Transitional Care - Final Report
Grant Final Report
Grant ID: R18HS018183
Medication Reconciliation Technology to Improve
Quality of Transitional Care
Inclusive Project Dates: 09/30/09 – 07/31/13
Principal Investigator:
Michael Weiner
Team Member…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/continuing-ed/moc_haguide.pdf
January 14, 2016 - Health Assessment Module User Guide
Health Assessment Module User Guide
Reducing Barriers to Quality Assurance in Primary Care via
Maintenance of Certification Modules
Prepared for:
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, Maryland 20780
http://www…
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psnet.ahrq.gov/node/49531/psn-pdf
March 01, 2007 - Failure to Report
March 1, 2007
Spath P. Failure to Report. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/failure-report
Case Objectives
List common causes of medical errors.
Appreciate the magnitude of underreporting of adverse events.
List the common barriers to reporting adverse events and near misses…
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www.ahrq.gov/sites/default/files/2024-09/fowler-report.pdf
January 01, 2024 - Final Progress Report: Determining a Learning Curve for Complex Laparoscopic Gastrointestinal Surgery
Title Page
Final Progress Report
Determining a Learning Curve for Complex Laparoscopic
Gastrointestinal Surgery
Principal Investigator: Dennis L. Fowler, MD, MPH
Co-Investigator: R. Todd Ogden, PhD
Co-Investigato…
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psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
January 01, 2021 - Spotlight
Spotlight
Two Cases of Retained Vaginal Packing:
When Writing an Order is Not Enough
Source and Credits
• This presentation is based on the April 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Verna Gibbs, MD
o AHRQ W…
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psnet.ahrq.gov/node/33714/psn-pdf
July 01, 2011 - In Conversation with…William B. Munier, MD, MBA
July 1, 2011
In Conversation with…William B. Munier, MD, MBA. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
Editor's note: William B. Munier, MD, MBA, is the Director of the Center for Quality Improvement and
Pati…
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psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
September 01, 2017 - Missed Patient Assignment: Is Anyone There?
Citation Text:
Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
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psnet.ahrq.gov/node/49669/psn-pdf
November 01, 2012 - Transfusion Overload
November 1, 2012
Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfusion-overload
Case Objectives
Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit
below 30% are not supported by the evidence.…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/hospital-efficiency-resources.pdf
May 01, 2023 - Improving Value and Efficiency in Hospitals and Medical Offices: A Resource List for Users of the AHRQ SOPS Value and Efficiency Supplemental Item Sets
SOPS Value and Efficiency Supplemental Item Sets Resource List 1
Improving Value and Efficiency in Hospitals and
Medical Offices: A Resource List for Users of the…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/098-cusp-why-choose-cusp-approach.pptx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
AHRQ Safety Program for MRSA Prevention
Why Choose a CUSP Approach?
ICU & Non-ICU
AHRQ Pub. No. 25-0007
October 2024
AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU
AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU
Why Choose a CUSP Approach?
1
Educational Obje…
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www.ahrq.gov/hai/tools/mvp/modules/cusp/overview-cusp-mvp-facguide.html
February 01, 2017 - Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients: Facilitator Guide
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients
Say: …
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/child-hcahps-survey-english.pdf
May 12, 2016 - Child Hospital Survey
CAHPS® Hospital Survey
Version: Child Version
Language: English
File name: Child_HCAHPS_English_Survey_954a.docx
Last updated: May 12, 2016
Instructions for Front Cover
• Replace the cover of this document with your own front cover. Include a user-friendly title
and your own logo.
•…
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www.ahrq.gov/hai/cauti-tools/archived-webinars/health-literacy-slides.html
December 01, 2017 - Health Literacy and Patient and Family Engagement: Strategic Tools to Prevent CAUTI
Slide Presentation
Slide 1
Health Literacy and Patient and Family Engagement: Strategic Tools to Prevent CAUTI
Barbara Meyer Lucas, MD, MHSA
Project Consultant
Michigan Health & Hospital Association
Keystone Center fo…