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  1. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/assessment.html
    December 01, 2017 - On-Time Pressure Ulcer Assessment AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing The On-Time Pressure Ulcer Assessment incorporates elements from the Bates-Jensen Wound Assessment Tool (BWAT) with additional standardized treatment and intervention descriptors. The On-Time Pressur…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49687/psn-pdf
    August 21, 2013 - Emergency Error August 21, 2013 Symons NRA. Emergency Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/emergency-error Case Objectives State that emergency surgery is high risk and has high mortality. Appreciate that emergency laparotomy is a particularly high-risk procedure with a high likelihood of …
  3. psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
    June 17, 2010 - Late Anemia Following Rh Disease in a Newborn Citation Text: Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Schola…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73650/psn-pdf
    August 25, 2021 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax August 25, 2021 Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumoth…
  5. psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
    February 23, 2011 - Patient Identification Errors: A Systems Challenge Citation Text: Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Googl…
  6. psnet.ahrq.gov/web-mm/liposuction-gone-awry
    July 01, 2003 - Liposuction Gone Awry Citation Text: Yates JA. Liposuction Gone Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
  7. psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
    February 21, 2020 - Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. Citation Text: Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. …
  8. hcup-us.ahrq.gov/datainnovations/clinicalcontentenhancementtoolkit/hi26.jsp
    August 01, 2014 - Enhancing Hawaii Hospital Information Content: High-Level Analysis of Transmitted Laboratory Data. An official website of the Department of Health & Human Services Search All AHRQ Websites Careers…
  9. hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/or17.jsp
    August 01, 2014 - Overview of Link Plus An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs Email Updates …
  10. psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
    January 05, 2017 - Discontinued Medications: Are They Really Discontinued? Citation Text: Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: …
  11. psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
    October 01, 2018 - CVC Removal: A Procedure Like Any Other Citation Text: Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49869/psn-pdf
    July 02, 2019 - Failure to Rescue the Mother July 2, 2019 Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/failure-rescue-mother The Case A 27-year-old woman, G5 P2 A2, was first admitted to the hospital at 25 weeks of pregnancy for vaginal bleeding. An …
  13. psnet.ahrq.gov/web-mm/reconciling-doses
    August 14, 2017 - SPOTLIGHT CASE Reconciling Doses Citation Text: Federico F. Reconciling Doses. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
  14. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/062-protocol-training-decolonization-with-chg.pptx
    October 01, 2024 - AHRQ Safety Program for MRSA Prevention AHRQ Safety Program for MRSA Prevention Decolonization With Chlorhexidine Gluconate (CHG) Nursing Protocol Training ICU & Non-ICU AHRQ Pub. No. 25-0007 October 2024 AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU Decolonization With Chlorhexidine Gluconate (CHG) 1 E…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49804/psn-pdf
    September 01, 2017 - Transfusion Thresholds in Gastrointestinal Bleeding September 1, 2017 Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding Case Objectives Describe risk factors for poor outcome in patients w…
  16. Puh-Assessment (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.docx
    June 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing On-Time Pressure Ulcer Assessment The On-Time Pressure Ulcer Assessment incorporates elements from the Bates-Jensen Wound Assessment Tool (BWAT) with additional standardized treatment and intervention descriptors. The On-Time Pressure Ulcer Assess…
  17. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/engaging-srexec-facguide.docx
    January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle Slide Title and Commentary Slide Number and Slide Title Slide Engaging Senior Executives in Care of Mechanically Ventilated Patients SAY: In this module, we will discuss the importance of senior executive engagement on your safety program team. Slide 1 Lear…
  18. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
    January 01, 2022 - Spotlight Spotlight False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy Source and Credits • This presentation is based on the September 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by:…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60173/psn-pdf
    March 30, 2020 - In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD March 30, 2020 In Conversation With.. Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md Editor’s note: Ann D. Gaffey, RN, …
  20. psnet.ahrq.gov/web-mm/around-block
    March 04, 2020 - Around the Block Citation Text: Minichiello T. Around the Block. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …