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  1. Thin Air | PSNet

    psnet.ahrq.gov/web-mm/thin-air
    March 01, 2006 - SPOTLIGHT CASE Thin Air Citation Text: Gaba DM. Thin Air. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

  2. Microsoft PowerPoint - FINAL Dec Spotlight_Code Status vs Care Status.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL Dec Spotlight_Code Status vs Care Status.pptx Spotlight Code Status vs. Care Status Source and Credits • This presentation is based on the December 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Rebe…

  3. Establishing a Business Case for Health Information Exchange (HIE) (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/UHIN_BusinessCaseReport.pdf
    November 01, 2005 - Establishing a Business Case for Health Information Exchange (HIE)                                                                                                                                                                                                                                                      …

  4. Medication Reconciliation Technology to Improve Quality of Transitional Care - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/publication/r18hs018183-weiner-final-report-2013.pdf
    January 01, 2013 - Medication Reconciliation Technology to Improve Quality of Transitional Care - Final Report Grant Final Report Grant ID: R18HS018183 Medication Reconciliation Technology to Improve Quality of Transitional Care Inclusive Project Dates: 09/30/09 – 07/31/13 Principal Investigator: Michael Weiner Team Member…

  5. STATISTICAL BRIEF #374: Changes in Adult Asthma Medication Use and Expenditures, United States, 1998-1999 to 2008-2009

    meps.ahrq.gov/data_files/publications/st374/stat374.shtml
    July 01, 2012 - STATISTICAL BRIEF #374: Changes in Adult Asthma Medication Use and Expenditures, United States, 1998-1999 to 2008-2009   Skip to main content An official website of the Department of Health & Human Services …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49531/psn-pdf
    March 01, 2007 - Failure to Report March 1, 2007 Spath P. Failure to Report. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/failure-report Case Objectives List common causes of medical errors. Appreciate the magnitude of underreporting of adverse events. List the common barriers to reporting adverse events and near misses…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49829/psn-pdf
    May 01, 2018 - Root Cause Analysis Gone Wrong May 1, 2018 Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney transplant. A suitabl…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857259/psn-pdf
    November 30, 2023 - Medication Mix-Up Leads to Patient Death November 30, 2023 Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death The Case  An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865778/psn-pdf
    May 29, 2024 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement May 29, 2024 Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/navigating-complications-unint…

  10. Screening for Depression in Adults | Agency for Healthcare Research and Quality

    www.ahrq.gov/prevention/resources/depression/depsum1.html
    April 01, 2013 - Screening for Depression in Adults Summary of the Evidence The summaries of the evidence briefly present evidence of effectiveness for preventive health services used in primary care clinical settings, including screening tests, counseling, and chemoprevention. They summarize the more detailed Systematic Evid…

  11. Psn-Pdf (pdf file)

    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-…

  12. Final Progress Report: Using Performance Measurement To Improve the Quality and Safety of Healthcare (pdf file)

    www.ahrq.gov/sites/default/files/2024-11/ballard-report.pdf
    January 01, 2024 - Final Progress Report: Using Performance Measurement To Improve the Quality and Safety of Healthcare Element 1. Title Page: Using Performance Measurement to Improve the Quality and Safety of Healthcare Report on The International Society for Quality in Health Care (ISQua) 6th International Summit on Indic…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49402/psn-pdf
    June 01, 2003 - Inappropriate Antibiotic Use June 1, 2003 Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use The Case A 41-year-old woman presented to the hospital with acute renal failure, which came to be diagnosed as a first presentation of s…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33714/psn-pdf
    July 01, 2011 - In Conversation with…William B. Munier, MD, MBA July 1, 2011 In Conversation with…William B. Munier, MD, MBA. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba Editor's note: William B. Munier, MD, MBA, is the Director of the Center for Quality Improvement and Pati…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855057/psn-pdf
    October 31, 2023 - Addressing Workplace Violence and Creating a Safer Workplace October 31, 2023 Jones CB, Sousane Z, Mossburg S. Addressing Workplace Violence and Creating a Safer Workplace. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace While violence in the w…

  16. The Safety Challenges of Supervision and Night Coverage in Academic Residency | PSNet

    psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
    February 21, 2024 - The Safety Challenges of Supervision and Night Coverage in Academic Residency Citation Text: Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019…

  17. Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
    March 12, 2008 - Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes Karla Miller, PharmD; Manisha Shah, MBA, RT; Lau…

  18. Missed Patient Assignment: Is Anyone There? | PSNet

    psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
    September 01, 2017 - Missed Patient Assignment: Is Anyone There? Citation Text: Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73456/psn-pdf
    June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia June 30, 2021 Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49669/psn-pdf
    November 01, 2012 - Transfusion Overload November 1, 2012 Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfusion-overload Case Objectives Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit below 30% are not supported by the evidence.…
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