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psnet.ahrq.gov/node/854848/psn-pdf
October 31, 2023 - Delay in Malignancy Diagnosis Reflects Systemic Failures
October 31, 2023
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
The Case
A 32-year-old man presented to the hospital with…
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psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-pandemic
October 30, 2024 - A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic
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April 27, 2022
Innovation
Conta…
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psnet.ahrq.gov/node/49482/psn-pdf
May 01, 2005 - Pregnant With Danger
May 1, 2005
Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pregnant-danger
The Case
A 35-year-old woman, 38 weeks pregnant, presented to the emergency department (ED) in the middle of
the night complaining of left leg pain. She also had so…
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psnet.ahrq.gov/node/49549/psn-pdf
December 06, 2007 - Elopement
December 1, 2007
Gerardi D. Elopement. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/elopement
Case Objectives
Define elopement and differentiate it from wandering and leaving against medical advice.
Identify leading contributors to elopement events.
Describe strategies for preventing elopement…
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psnet.ahrq.gov/node/49639/psn-pdf
November 01, 2011 - Near Miss with Bedside Medications
November 1, 2011
Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications
Case Objectives
Understanding the definition of near miss—also known as close call.
Appreciate the importance of close calls in reducin…
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psnet.ahrq.gov/node/49606/psn-pdf
August 01, 2010 - Weighing In on Surgical Safety
August 1, 2010
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/weighing-surgical-safety
Case Objectives
Identify the comorbidites associated with obesity that place patients at higher risk for surgical
complications.
Un…
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psnet.ahrq.gov/node/838855/psn-pdf
October 27, 2022 - False Assumptions Result in a Missed Pneumothorax
after Bronchoscopy with Transbronchial Biopsy.
October 27, 2022
Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy
with Transbronchial Biopsy. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/false-assumptions-resul…
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psnet.ahrq.gov/node/854897/psn-pdf
October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical
Record Causing an Accidental Medication Overdose
October 31, 2023
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an
Accidental Medication Overdose. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/weight-and-…
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psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
April 09, 2014 - SPOTLIGHT CASE
The Hazards of Distraction: Ticking All the EHR Boxes
Citation Text:
Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - The Forgotten Line
Citation Text:
Render ML. The Forgotten Line. 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 RIS …
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psnet.ahrq.gov/node/842923/psn-pdf
February 01, 2023 - Aspergillus Mediastinitis & Endocarditis in a Pediatric
Patient Complicating Cardiac Surgery and Bedside Chest
Closure.
February 1, 2023
Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient
Complicating Cardiac Surgery and Bedside Chest Closure. PSNet [internet]. …
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/understanding-cms-patient-safety-measure-hospitals-webcast.pdf
July 08, 2025 - Understanding the CMS Patient Safety Structural Measure Requirements for Hospitals
Understanding the CMS Patient Safety Structural
Measure Requirements for Hospitals
Webcast
July 8, 2025
12:00-12:45 PM ET
Technical Info
• Audio issues
• Poor connection
• Use Q&A to submit questions
2
Today’s Speakers
Jo…
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www.ahrq.gov/hai/tools/mvp/modules/technical/pain-mgmt-slides.html
January 01, 2017 - Evidence Behind Pain, Agitation, and Delirium: Assessments and Sedation Management: Slide Presentation
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients
Evidence Behind Pain, Agitation, and Delirium: Assessments and Sedation Manageme…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/overview-cuspmvp-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients
SAY:
Today, we will be giving you an overview of the Comprehensive Unit-based Safety Program…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.pdf
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
Ulc…
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www.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
August 01, 2022 - Implementation Guide for the CANDOR Process
Communication and Optimal Resolution Toolkit
Purpose: The Toolkit Implementation Guide is a reference for organizational leaders who are committed to improving their response to unexpected patient harm events. The guide describes the CANDOR process, implementatio…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4b_pdi02-pressureulcer-bestpractices.pdf
January 01, 2012 - Selected Best Practices and Suggestions for Improvement
Pediatric Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4b
Selected Best Practices and Suggestions for Improvement
PDI 02: Pressure Ulcer
Why focus on pressure ulcers in children?
• Although childre…
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www.ahrq.gov/pqmp/implementation-qi/toolkit/antipsychotic/other-resources.html
September 01, 2021 - Safe and Judicious Use of Antipsychotic Medications in Children and Adolescents Toolkit
Other Resources
Previous Page Next Page
Table of Contents
Safe and Judicious Use of Antipsychotic Medications in Children and Adolescents Toolkit
Introduction
Overview
About the Measure
Key Driver Diagram…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/nicutoolkit.pdf
January 01, 2004 - Transitioning Newborns from NICU to Home: A Resource Toolkit
Transitioning Newborns
from NICU to Home:
A Resource Toolkit
Table of Contents
Overview: Improving the Quality of the Transition Home from the NICU............................1
Tools f…
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psnet.ahrq.gov/toolkits
March 01, 2025 - Toolkits
Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols.
Want to submit a Toolkit?
Has your organization deve…