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psnet.ahrq.gov/node/846563/psn-pdf
March 21, 2023 - Impact of System Failures on Healthcare Workers
March 21, 2023
Zangaro G, Van CM, Mossburg S. Impact of System Failures on Healthcare Workers . PSNet [internet].
2023.
https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
Introduction
The March 2022 conviction of RaDonda Vaught, a former nu…
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psnet.ahrq.gov/web-mm/empty-handoff
August 01, 2017 - Empty Handoff
Citation Text:
Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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psnet.ahrq.gov/web-mm/moving-pains
August 17, 2017 - SPOTLIGHT CASE
Moving Pains
Citation Text:
Schell H, Wachter R. Moving Pains. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
January 01, 2024 - Spotlight
Spotlight
A Fatal Twist in Pseudohyperkalemia
1
Source and Credits
This presentation is based on the August 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Le…
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psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!
Citation Text:
Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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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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hcup-us.ahrq.gov/datainnovations/clinicalcontentenhancementtoolkit/ny14.pdf
March 20, 2012 - FAQs for Using Clinically Enhanced Claims Data to Guide Selection of Coronary Procedures
NYSDOH Updated FAQs March 20, 2012 Page 1
New York State Department of Health
Using Clinically Enhanced Claims Data to Guide Selection of Coronary Procedures
Frequently Asked Questions and Answers
1. What is th…
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
1
Source and Credits
This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Elizabeth Gould, NP-C, COR…
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psnet.ahrq.gov/node/837659/psn-pdf
July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging
July 8, 2022
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
The Cases
Case #1: A 42-year-old woman admitted with…
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cds.ahrq.gov/sites/default/files/workgroups/38971/CDS_Connect_Work_Group_December_2021.pdf
January 01, 2021 - December 2021 CDS Connect Work Group Call
December 2021 CDS Connect Work Group Call
Agenda
Schedule Topic
3:00 – 3:02 Roll Call, Michelle Lenox (MITRE)
3:02 – 3:05 Review of the Agenda, Michelle Lenox (MITRE)
3:05 – 3:10 Kick-off “One More Step” in Patient Partnering, Michelle Lenox (MITRE)
3:10 – 3:50
Roundt…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/measuredesc-ltvv-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Measure Descriptions for
Low Tidal Volume Ventilation
SAY:
In this module, you will learn about the data measures and definitions you will use to evaluate low tidal volume ventilation, or LTVV, proce…
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www.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-case-study-work-around.pdf
June 02, 2025 - Creating a Work-Around to Implement Fall Risk Screening For Older Adults Using Appointment Notes Case Study
Focus on High Leverage Change: Risk Assessment
Creating a Work-Aro…
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cdsic.ahrq.gov/cdsic/planning-reporting-user-guide
September 23, 2024 - :
Skip to main content
HHS.gov
Menu
Main navigation
CDS Home
CDS Innovation Collaborative
An official website of the Department of Health & Human Services
…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-5.html
March 01, 2022 - Improving Education—A Key to Better Diagnostic Outcomes
Next Steps and Barriers
Previous Page Next Page
Table of Contents
Improving Education—A Key to Better Diagnostic Outcomes
Introduction
Foundations of Diagnosis Education
Current State of Diagnosis Education
Competencies To Improve Diagn…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/115-daily-goals-icu-checklist.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
Intensive Care Unit (ICU) Daily Goals Checklist
ICU & Non-ICU
Problem statement:
Clear communication among healthcare providers is essential. Communication failures lead to patient harm, increased length of stay, provider dissatisfaction, and staff turnover. Effective communic…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-b.docx
April 24, 2015 - URINARY CATHETERIZATION – Sample Policy
AHRQ Safety Program for Reducing CAUTI in Hospitals
Appendix B. Urinary Catheterization – Sample Policy
Purpose
The purpose of urinary catheterization is to facilitate urinary drainage when medically necessary. Urinary catheters should be evaluated every day for need and remo…
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www.ahrq.gov/hai/cusp/modules/engage/exec-slides.html
December 01, 2012 - Engage the Senior Executive
The Engage the Senior Executive module of the CUSP Toolkit focuses on the role and responsibilities of the senior executive within the CUSP team. Engaging a senior executive to partner with a unit will bridge the gap between senior management and frontline providers and will facilita…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/nurse_empower-slides/How-CUSP-Enables-Nurse-Empowerment-Nov-15-2011-508.ppt
January 01, 2011 - Project Report - Lean Sigma
CLABSI Supplemental Call Series
How CUSP Enables Nurse Empowerment
November 15, 2011
Presenters:
Pat Posa, RN, BSN, MSA
Joanne Timmel, MSN, RN, NE-BC
Slide *
CLABSI Supplemental Call Series
Pat Posa, RN, BSN, MSA
System Performance Improvement Leader
St. Joseph Mercy Heath Syste…
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psnet.ahrq.gov/node/33567/psn-pdf
June 15, 2024 - Handoffs
June 15, 2024
Handoffs and Signouts. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/handoffs
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Backgroun…
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psnet.ahrq.gov/innovation/battle-buddies-rapid-deployment-psychological-resilience-intervention-health-care
September 09, 2020 - EMERGING INNOVATIONS
Battle Buddies: rapid deployment of a psychological resilience intervention for health care workers during the COVID-19 pandemic
Citation Text:
Albott CS, Wozniak JR, McGlinch BP, et al. Battle Buddies: rapid deployment of a psychological resilience intervention for health car…