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  1. Waiting Too Long | PSNet

    psnet.ahrq.gov/web-mm/waiting-too-long
    February 01, 2013 - WebM&M Cases Uterine Artery Injury during Cesarean Delivery Leads

  2. RaDonda Vaught says some system practices contributed to fatal mistake. | PSNet

    psnet.ahrq.gov/issue/vaught-says-some-system-practices-contributed-fatal-mistake
    September 29, 2021 - Newspaper/Magazine Article RaDonda Vaught says some system practices contributed to fatal mistake. Citation Text: RaDonda Vaught says some system practices contributed to fatal mistake. Clark C. MedPage Today. March 14, 2024. Copy Citation Save Save to…

  3. The Shift Coupon: an innovative method to monitor adverse events. | PSNet

    psnet.ahrq.gov/issue/shift-coupon-innovative-method-monitor-adverse-events
    June 25, 2010 - Study The Shift Coupon: an innovative method to monitor adverse events. Citation Text: Kellogg VA, Havens DS. The Shift Coupon: an innovative method to monitor adverse events. J Nurs Care Qual. 2006;21(1):49-55. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X…

  4. Improving Electronic Health Records Patient Education Materials - 2012 | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/improving-electronic-health-records-patient-education-materials/annual-summary/2012
    January 01, 2012 - Improving Electronic Health Records Patient Education Materials - 2012 Project Name Improving Electronic Health Records Patient Education Materials Principal Investigator Shoemaker, Sarah Organization Abt Associates, Inc. Funding Mechanism National Resource Center T…

  5. Remembering to learn: the overlooked role of remembrance in safety improvement. | PSNet

    psnet.ahrq.gov/issue/remembering-learn-overlooked-role-remembrance-safety-improvement
    February 28, 2024 - Commentary Remembering to learn: the overlooked role of remembrance in safety improvement. Citation Text: Macrae C. Remembering to learn: the overlooked role of remembrance in safety improvement. BMJ Qual Saf. 2017;26(8):678-682. doi:10.1136/bmjqs-2016-005547. Copy Citation Format:…

  6. Cancer drug shortages are creating dire circumstances for some patients. | PSNet

    psnet.ahrq.gov/issue/cancer-drug-shortages-are-creating-dire-circumstances-some-patients
    September 21, 2022 - Newspaper/Magazine Article Cancer drug shortages are creating dire circumstances for some patients. Citation Text: Cancer drug shortages are creating dire circumstances for some patients. Lovelace B, Jr, Kopf M. NBC. April 11, 2023. Copy Citation Save Save to yo…

  7. Community Heath Care Association of New York State Recruitment Outreach Script (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/recruitment-script-ny.pdf
    June 02, 2025 - Community Heath Care Association of New York State Recruitment Outreach Script Audience: CMO/CEO/QI lead script Hello Mr./Ms./Doctor, My name is and I am calling you on behalf of CHCANYS. Is this a convenient time to speak? IF NO, is there a convenient time we could speak? I would like to share information wi…

  8. Drug shortages continue to compromise patient care. | PSNet

    psnet.ahrq.gov/issue/drug-shortages-continue-compromise-patient-care
    February 24, 2016 - Newspaper/Magazine Article Drug shortages continue to compromise patient care. Citation Text: Drug shortages continue to compromise patient care. ISMP Medication Safety Alert! Acute Care Edition. January 11, 2018;23:1-4. Copy Citation Save Save to your library …

  9. Office-based anesthesia: safety and outcomes. | PSNet

    psnet.ahrq.gov/issue/office-based-anesthesia-safety-and-outcomes
    February 18, 2019 - Review Office-based anesthesia: safety and outcomes. Citation Text: Shapiro FE, Punwani N, Rosenberg NM, et al. Office-Based Anesthesia. Anesth Analg. 2014;119(2):276-285. doi:10.1213/ane.0000000000000313. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNo…

  10. DSF Measures 2-3 Attachment 11.1 (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA205-Materials_XIA.pdf
    June 02, 2025 - DSF Measures 2-3 Attachment 11.1 Attachment 11A.1 Additional ICD-9 and ICD-10 Codes ICD-9-CM Codes Used to Describe a Positive Developmental Screening Result 1. 783.42 Delayed milestones 2. 315.31 Language disorder, developmental 3. 315.9 Learning disorder, NOS 4. 348.3 Static encephalo…

  11. DSF Measures 2-3 Attachment 11.1 (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA204-Materials_XIA.pdf
    June 02, 2025 - DSF Measures 2-3 Attachment 11.1 Attachment 11A.1 Additional ICD-9 and ICD-10 Codes ICD-9-CM Codes Used to Describe a Positive Developmental Screening Result 1. 783.42 Delayed milestones 2. 315.31 Language disorder, developmental 3. 315.9 Learning disorder, NOS 4. 348.3 Static encephalo…

  12. Five Medication Safety Tips for Older Adults. | PSNet

    psnet.ahrq.gov/issue/five-medication-safety-tips-older-adults
    April 23, 2012 - Fact Sheet/FAQs Five Medication Safety Tips for Older Adults. Citation Text: Five Medication Safety Tips for Older Adults. FDA Consumer Health Information. Silver Spring, MD: US Food and Drug Administration; February 15, 2024. Copy Citation Save Save to your libra…

  13. Learning from patient safety incidents: creating participative risk regulation in healthcare. | PSNet

    psnet.ahrq.gov/issue/learning-patient-safety-incidents-creating-participative-risk-regulation-healthcare
    February 28, 2024 - Commentary Learning from patient safety incidents: creating participative risk regulation in healthcare. Citation Text: Macrae C. Learning from patient safety incidents: Creating participative risk regulation in healthcare. Health Risk Soc. 2008;10(1). doi:10.1080/13698570701782452. …

  14. Improving Care Transitions of Hospitalized Patients With the Pharmacy Integrated Transitions Program | Digital Healthcare Research

    digital.ahrq.gov/2020-year-review/research-summary/improving-care-transitions-hospitalized-patients-pharmacy-integrated-transitions-program
    January 01, 2020 - Improving Care Transitions of Hospitalized Patients With the Pharmacy Integrated Transitions Program Standardizing the hospital-to-skilled nursing facility transition by using a structured handoff between clinical teams along with a pharmacist to monitor patient medications during the transition may improve care co…

  15. 2014 Chartbooks | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/womenhealth/wm-chartbooks.html
    March 01, 2020 - Chartbook on Women's Health Care 2014 Chartbooks Previous Page Next Page Table of Contents Chartbook on Women's Health Care Acknowledgments Women's Health Care Key Findings of the 2014 QDR 2014 Chartbooks Access to Health Care Affordability Communication and Care Coordination Effec…

  16. Engineering Patient Safety in Radiation Oncology: University of North Carolina's Pursuit for High Reliability and Value Creation. | PSNet

    psnet.ahrq.gov/issue/engineering-patient-safety-radiation-oncology-university-north-carolinas-pursuit-high
    May 04, 2016 - Book/Report Engineering Patient Safety in Radiation Oncology: University of North Carolina's Pursuit for High Reliability and Value Creation. Citation Text: Engineering Patient Safety in Radiation Oncology: University of North Carolina's Pursuit for High Reliability and Value Creation. M…

  17. e3iVR: Conference on Ethics in Investigational and Interventional Uses of Immersive VR - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/r13hs024833-gill-final-report-2017.pdf
    January 01, 2017 - Ponto leads multiple funded research projects that utilize VR to better understand the context of the

  18. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon | PSNet

    psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
    January 29, 2021 - WebM&M Cases An Incomplete Anesthesia History Leads

  19. In Conversation With... Freya Spielberg, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
    September 28, 2022 - In Conversation With... Freya Spielberg, MD, MPH September 28, 2022  Also Read the Essay Citation Text: In Conversation With.. Freya Spielberg, MD, MPH. PSNet [internet]. 2022.In Conversation With... Freya Spielberg, MD, MPH. PSNet [internet]. Rockville (MD): Agen…

  20. In Conversation with...Patrick Tighe about Artificial Intelligence | PSNet

    psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
    March 27, 2024 - In some cases, just taking that second look at a problem with this set of AI-fueled lenses leads us to … December 1, 2006 WebM&M Cases Medication Mix-Up Leads
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