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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49662/psn-pdf
    August 01, 2012 - Wrong Turn through Colon: Misplaced PEG August 1, 2012 Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg The Case An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…

  2. Written Signout: It Only Works If You Use The Right One | PSNet

    psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one
    April 24, 2018 - Written Signout: It Only Works If You Use The Right One Citation Text: Lewis K, Rosenbluth G. Written Signout: It Only Works If You Use The Right One. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73229/psn-pdf
    May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities May 26, 2021 Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33709/psn-pdf
    July 01, 2011 - What Have We Learned About Safe Inpatient Handovers? March 1, 2011 Kripalani S. What Have We Learned About Safe Inpatient Handovers? PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers Perspective The care of hospitalized patients is marked by numerous tra…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49794/psn-pdf
    May 01, 2017 - Communication Error in a Closed ICU May 1, 2017 Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/communication-error-closed-icu The Case A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney transplant), co…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866848/psn-pdf
    September 25, 2024 - In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement September 25, 2024 Thomas E, Mossburg S, Lee M. In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement. …

  7. Bloody BP Cuff | PSNet

    psnet.ahrq.gov/web-mm/bloody-bp-cuff
    June 21, 2016 - Bloody BP Cuff Citation Text: Madan AK. Bloody BP Cuff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  8. New Patient Mistakenly Checked in as Another | PSNet

    psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
    October 01, 2013 - New Patient Mistakenly Checked in as Another Citation Text: Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar B…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49605/psn-pdf
    June 01, 2010 - Acute Respiratory Arrest in Pregnancy June 1, 2010 Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy The Case A 35-year-old woman was 38 weeks pregnant with twins (G3P2). When she developed acute onset of shortness of breath an…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49458/psn-pdf
    September 01, 2004 - Poor Prognosis September 1, 2004 Lamont EB. Poor Prognosis. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/poor-prognosis Case Objectives Understand the current limitations of physicians' ability to provide prognoses. List the variables that can be used to guide treatment decisions and prognostication in e…

  11. Primary Workaround, Secondary Complication | PSNet

    psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
    January 24, 2018 - Primary Workaround, Secondary Complication Citation Text: Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar B…

  12. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
    August 01, 2014 - PowerPoint Presentation Spotlight Pitfalls in Diagnosing Necrotizing Fasciitis This presentation is based on the July/August 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Terence Goh, MBBS, Department of Plastic Surgery, Singapore General Hos…

  13. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallspximpl-ig.pdf
    June 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention 1 On-Time Falls Prevention: Implementation AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training Implementatio…

  14. Heart Healthy Ohio Initiative Charter: August 2021 (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/57-ohio-hhoi-charter.pdf
    August 01, 2021 - Heart Healthy Ohio Initiative Charter: August 2021 Heart Healthy Ohio Initiative Charter August 2021 …

  15. Falls Prevention Self-Assessment Worksheet - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallspxselfassessment.pdf
    June 02, 2025 - Falls Prevention Self-Assessment Worksheet - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Agency for Healthcare Research and Quality Safety Program for Nursing Homes: On-Time Prevention AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Falls Prevention Self-Assessment Workshee…

  16. Self-Management Support Module User Guide (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/continuing-ed/moc_smsguide.pdf
    April 12, 2016 - Self-Management Support Module User Guide Self-Management Support Module User Guide Reducing Barriers to Quality Assurance in Primary Care via Maintenance of Certification Modules http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/continuing-ed/moc_sm…

  17. 2023 Intervention Content Diet Activity (xls file)

    cds.ahrq.gov/sites/default/files/cds/artifact/1071/2023_Intervention_Content_Diet_Activity.xlsx
    January 01, 2023 - Example Intervention Text Example Patient-Facing Intervention Text: Healthy Diet and Physical Activity for CVD Prevention in Adults with CVD Risk Factors The following resources, along with the content resources listed on the next tab, are publicly available to artifact implementers if they elect to adjust the inte…

  18. SOPS® Value and Efficiency Supplemental Items for the SOPS Hospital Survey - Spanish (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/spanish-hospital-ve-supp-item-set-2022.pdf
    January 01, 2022 - SOPS® Value and Efficiency Supplemental Items for the SOPS Hospital Survey - Spanish SOPS® Value and Efficiency Supplemental Item Set for the SOPS Hospital Survey 2.0 Language: Spanish • Purpose: This supplemental item set was designed for use with the core SOPS® Hospital Survey Version 2.0 to help hospitals as…

  19. PowerPoint Presentation

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/teach-back-slides-final508.pptx
    June 02, 2025 - PowerPoint Presentation Teach-Back AHRQ Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families The Agency for Healthcare Research and Quality, or AHRQ, funded the development of a Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families. A…

  20. TeamSTEPPS® Diagnosis Improvement: Module 5 Situation Monitoring To Improve Diagnosis - Facilitator’s Notes (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module5-presenters-notes.pdf
    January 10, 2022 - TeamSTEPPS® Diagnosis Improvement: Module 5 Situation Monitoring To Improve Diagnosis - Facilitator’s Notes Slide 1 TeamSTEPPS® for Diagnosis Improvement                                                                                                                                                          …
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