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psnet.ahrq.gov/node/860049/psn-pdf
January 04, 2024 - Myasthenia Crisis after a Delayed Diagnosis in a
Medically Complex Patient.
January 4, 2024
Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. PSNet [internet].
2024.
https://psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
The Case
A 9…
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psnet.ahrq.gov/node/50842/psn-pdf
January 29, 2020 - Patient Identification Errors: A Systems Challenge
January 29, 2020
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
The Cases
The following four events involving five patients all involved…
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psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-and-improve-health
February 26, 2025 - Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes
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March 29, 2023
Innovation
Co…
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www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual/procedure-manual-section-2-topic-selection-prioritization-and-updating
June 22, 2025 - Procedure Manual Section 2. Topic Selection, Prioritization, and Updating
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The Task Force has a large library of current topics and frequently receives nominations for new top…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
August 01, 2022 - Module 5: Response and Disclosure
AHRQ Communication and Optimal Resolution Toolkit
Facilitator Notes
Say:
In Module 5 of the CANDOR Toolkit, we will discuss the Response and Disclosure component of the CANDOR process.
Slide 1
Say:
The goal of this module is to:
Define…
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psnet.ahrq.gov/web-mm/dangerous-dapsone
January 10, 2011 - Dangerous Dapsone
Citation Text:
Bookwalter T. Dangerous Dapsone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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hcup-us.ahrq.gov/reports/race/GeographicInfoIB.pdf
April 01, 2011 - MAINTAIN AND EXPAND
THE HEALTHCARE COST AND UTILIZATION PROJECT (HCUP)
Contract No. HHSA-290-2006-00009-C
USING GEOGRAPHIC INFORMATION TO
TARGET HEALTH DISPARITIES: STATE EXPERIENCE
September 20, 2011
Prepared by:
Denise Osborn, JD, MPH
Larry Hinkle
Jill Ro…
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psnet.ahrq.gov/node/33762/psn-pdf
March 01, 2014 - In Conversation With… Alison Holmes, MD, MPH
March 1, 2014
In Conversation With… Alison Holmes, MD, MPH. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph
Editor's note: Dr. Alison Holmes is Director of Infection Prevention and Control at Imperial College
Healthcare NHS …
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psnet.ahrq.gov/node/33816/psn-pdf
October 01, 2016 - In Conversation With… Richard Platt, MD, MSc
October 1, 2016
In Conversation With… Richard Platt, MD, MSc. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
Editor's note: Dr. Platt is Professor and Chair of the Harvard Medical School Department of Population
Medicine. He…
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psnet.ahrq.gov/node/49739/psn-pdf
August 21, 2015 - Breathe Easy: Safe Tracheostomy Management
August 21, 2015
Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
The Case
A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumo…
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psnet.ahrq.gov/node/49625/psn-pdf
May 01, 2011 - Pocket Syringe Swap
May 1, 2011
Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/pocket-syringe-swap
The Case
A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for
postoperative pain management. Surgery proceeded uneventfully under…
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digital.ahrq.gov/sites/default/files/docs/page/0_Overview_0.pdf
July 13, 2007 - 0_Overview
July 13, 2007
Privacy and Security Solutions for
Interoperable Health Information
Exchange
Privacy and Security Assessment of Variation
Toolkit
Prepared for
Jonathan White, MD, Director of Health IT
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville,…
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psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
August 10, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Diagnostic Errors Case Studies
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/suicidality
January 01, 2024 - An official website of the Department of Health & Human Services
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digital.ahrq.gov/ahrq-funded-projects/evaluating-impact-acpoecds-system-outcomes
January 01, 2023 - Evaluating the Impact of an ACPOE/CDS System on Outcomes
Project Final Report ( PDF , 806.9 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHR…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4a_combo_psi03-pressureulcer-bestpractices.pdf
January 01, 2012 - Selected Best Practices and Suggestions for Improvement
Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
Selected …
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psnet.ahrq.gov/web-mm/dangerous-detour
November 28, 2018 - The Dangerous Detour
Citation Text:
Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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www.ahrq.gov/ncepcr/tools/obesity/obpcp1.html
May 01, 2014 - Integrating Primary Care Practices and Community-based Resources to Manage Obesity
Chapter 1: Attaining Zoning and Building Permits
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Table of Contents
Integrating Primary Care Practices and Community-based Resources to Manage Obesity
Acknowledgements
Support
Foreword
O…
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psnet.ahrq.gov/perspective/patient-safety-primary-care
January 31, 2020 - Annual Perspective
Patient Safety in Primary Care
February 21, 2020
View more articles from the same authors.
Citation Text:
Schiff G, Hall KK, Fitall E. Patient Safety in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…
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effectivehealthcare.ahrq.gov/sites/default/files/module-iii-points-of-engagement-in-the-ehc-program.pdf
May 29, 2025 - Module III: Points of Engagement in the EHC Program
…