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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/33885/psn-pdf
August 01, 2019 - In Conversation With… Susan Smith, MD
August 1, 2019
In Conversation With… Susan Smith, MD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-susan-smith-md
Editor's note: Dr. Smith, a family medicine physician, is chief faculty practices officer for UCSF Health.
Over the past 3–4 years, the …
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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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psnet.ahrq.gov/node/49732/psn-pdf
May 01, 2015 - Errors in Sepsis Management
May 1, 2015
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/errors-sepsis-management
Case Objectives
Define sepsis, severe sepsis, and septic shock.
Describe the severe sepsis/septic shock resuscitation bundle.
Recognize commonly encou…
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www.ahrq.gov/hai/tools/mvp/modules/cusp/overview-cusp-mvp-facguide.html
February 01, 2017 - Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients: Facilitator Guide
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients
Say: …
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/translating-cahps-surveys.pdf
January 17, 2017 - Translating CAHPS Surveys
Translating CAHPS® Surveys
Contents
Purpose of this Document ............................................................................................................................. 1
Select Translation Team Members ..................................................................…
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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/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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www.ahrq.gov/sites/default/files/2024-10/smucker-report.pdf
January 01, 2024 - Final Progress Report: Patient Safety in Hospice Care
AHRQ Grant Final Progress Report
Title of Project: Patient Safety in Hospice Care
Principal Investigator: Douglas R. Smucker, MD, MPH, Adjunct Professor, University
of Cincinnati Department of Family and Community Medicine
Team Members:
• Nancy Elder, MD, Ass…
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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/836841/psn-pdf
June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered
Nurses and Paramedics To Provide Home Visits to
Recently Discharged Patients at Highest Risk for Hospital
Readmission
April 7, 2022
https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-
paramedics-provide-home
Sum…
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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/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
Save
Save to your library
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April 27, 2022
Innovation
Conta…
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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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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.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
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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/evidencenow/results/research/cpcq-scoring.pdf
May 01, 2017 - Scoring CPCQ
1
Scoring the Change Process Capability
Questionnaire Strategies Items:
Current Plan
National Evaluation Team
May 1, 2017
2
Introduction
The RFA from AHRQ for EvidenceNOW:
http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-14-008.html
described the required measures of practice…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm3a.html
October 01, 2014 - Designing and Implementing Medicaid Disease and Care Management Programs
Section 3: Selecting and Targeting Populations for a Care Management Program (continued)
Previous Page Next Page
Table of Contents
Designing and Implementing Medicaid Disease and Care Management Programs
Introduction
Sectio…
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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/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - Getting the Diagnosis Both Right and Wrong
Citation Text:
Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3…