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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…
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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
…
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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…
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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…
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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.
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Format:
Googl…
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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…
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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.
…
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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…
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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
…
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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.
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Format:
…
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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.
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Format:
Google Scholar BibTeX EndNote X3 XML End…
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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 …
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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.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
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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…
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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…
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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…
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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…
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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:…
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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, …
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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.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …