-
psnet.ahrq.gov/node/49463/psn-pdf
October 14, 2004 - Moved Too Soon
October 1, 2004
Lindenauer PK. Moved Too Soon. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/moved-too-soon
The Case
A 67-year-old man was admitted to a general hospital ward after undergoing a laminectomy. Two hours
after arriving, while the patient was still groggy from anesthesia, a nurs…
-
www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/naa-october-2024-webinar-slides.pdf
January 01, 2024 - NAA National Webinar October 2024
Workforce Safety and Well-being Webinar Series (Session 1)
Leadership Strategies that Improve
Workforce Safety and Well-being
NATIONAL WEBINAR SERIES
October 8, 2024
Housekeeping Instructions
• This webinar will be recorded and available for viewing on the NAA website
• Pleas…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.docx
May 01, 2017 - AHRQ Safety Program for Perinatal Care
Understand the Science of Safety for Perinatal Safety
Understand the Science of Safety for Perinatal Safety
SAY:
The Understand the Science of Safety module of the AHRQ Safety Program for Perinatal Care discusses the importance of understanding system design, safe design principl…
-
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
July 01, 2023 - Understand the Science of Safety for Perinatal Safety: Facilitator Guide
AHRQ Safety Program for Perinatal Care
Slide 1: Understand the Science of Safety for Perinatal Safety
Say:
The Understand the Science of Safety module of the AHRQ Safety Program for Perinatal Care discusses the importance of unders…
-
www.ahrq.gov/hai/cauti-tools/ena-slides/part2.html
October 01, 2020 - The Emergency Nurses Association Presents CAUTI Slides and Transcript
Part Two: Removing the Obstacles to Practice Change
Previous Page Next Page
Table of Contents
The Emergency Nurses Association Presents CAUTI Slides and Transcript
Opening Materials: Attribution, Objectives, Introduction, and Ma…
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapa.html
December 01, 2017 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Appendix A. References and Equipment Sources
Previous Page Next Page
Table of Contents
The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Chapter 1. Introduction and Program Ove…
-
www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/DiagnosticSafety-flier.pdf
November 01, 2024 - Diagnostic Safety Research
1
Diagnostic Safety Research
at the Agency for Healthcare
Research and Quality
Diagnostic Error
Diagnostic error is a significant and underrecognized threat to patient safety.
Diagnostic errors are common, consequential, and costly and contribute to avoidable suffering and
prevent…
-
www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-jul2023.pdf
November 03, 2023 - Federal Interagency Workgroup on Improving Diagnostic Safety: July Meeting Summary
Federal Interagency Workgroup:
Improving Diagnostic Safety and Quality in Healthcare
July Meeting Summary
Workgroup Goal: Established in response to Senate Report 115-150. The Senate Committee on
Appropriations requested that…
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology-references.html
April 01, 2025 - Exploration of Foundational Terminology and Paradigms for Improving Diagnosis
References
Previous Page
Table of Contents
Exploration of Foundational Terminology and Paradigms for Improving Diagnosis
Introduction
Perspectives on Diagnostic Improvement
Definitions of Diagnosis
Types of Evide…
-
psnet.ahrq.gov/node/49812/psn-pdf
November 01, 2017 - Specimen Almost Lost
November 1, 2017
Hehe YK. Specimen Almost Lost. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/specimen-almost-lost
The Case
A 29-year-old woman presented to the hospital with a rash that had spread across her legs and abdomen.
She was admitted to the medicine service for further evalu…
-
psnet.ahrq.gov/node/49473/psn-pdf
March 01, 2005 - On O.R. Off?
March 1, 2005
Leonard M. On O.R. Off? PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/or
The Case
An elderly man was admitted to the vascular surgery service with rest pain in his leg. Angiography
demonstrated peripheral artery disease with anatomy suitable for revascularization. A consulting
…
-
psnet.ahrq.gov/node/49727/psn-pdf
March 01, 2015 - Critical Opportunity Lost
March 1, 2015
Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/critical-opportunity-lost
The Case
A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. She
reported eating a heavy dinner the pre…
-
psnet.ahrq.gov/node/49791/psn-pdf
April 01, 2017 - Wrong-side Bedside Paravertebral Block: Preventing the
Preventable
April 1, 2017
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
The Case
An 84-year-old wo…
-
psnet.ahrq.gov/primer/radiation-safety
September 15, 2024 - Radiation Safety
Citation Text:
Radiation Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downl…
-
psnet.ahrq.gov/node/33727/psn-pdf
March 01, 2012 - Can Research Help Us Improve the Medical Liability
System?
March 1, 2012
Kachalia A. Can Research Help Us Improve the Medical Liability System? PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
Perspective
The United States medical malpractice liabili…
-
psnet.ahrq.gov/perspective/conversation-lorri-zipperer-ma
February 26, 2025 - In Conversation With… Lorri Zipperer, MA
November 1, 2015
Citation Text:
In Conversation With… Lorri Zipperer, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
For…
-
psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - Rethinking Root Cause Analysis
January 1, 2016
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
Annual Perspective 2016
Introduction
Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…
-
psnet.ahrq.gov/web-mm/discharged-blindly
October 26, 2022 - Discharged Blindly
Citation Text:
Iezzoni LI. Discharged Blindly. 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…
-
psnet.ahrq.gov/web-mm/secured-not-always-safe
October 01, 2015 - Secured But Not Always Safe
Citation Text:
Jahr JS, Hosseini P. Secured But Not Always Safe. 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 …
-
psnet.ahrq.gov/node/49757/psn-pdf
April 01, 2016 - Situational Awareness and Patient Safety
April 1, 2016
Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
The Case
A 40-year-old woman with a history of cirrhosis and known esophageal varices was admitted to the hospit…