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  1. Psn-Pdf (pdf file)

    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…
  2. www.ahrq.gov/ncepcr/tools/transform-qi/deliver-facilitation/modules/menus.html
    February 01, 2022 - Module Menus The Modules Introduction to the AHRQ Practice Facilitation Training Modules Starting with a Practice Facilitator Fundamentals Effective Meetings Introduction to Quality Improvement (QI) in Primary Care Model for Improvement and PDSA Cycles Process Mapping The 5 Whys and Fishbone…
  3. 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 …
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33808/psn-pdf
    May 01, 2016 - Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue May 1, 2016 Jacques S, Williams E. Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue Perspective Alarm fatigue occurs whe…
  7. Psn-Pdf (pdf file)

    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 …
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49532/psn-pdf
    March 15, 2007 - Back to Basics March 1, 2007 Hellman R. Back to Basics. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/back-basics The Case A 48-year-old woman with insulin-dependent diabetes mellitus presents to the emergency department with right upper quadrant pain, fever, and leukocytosis, prompting admission for pres…
  11. 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…
  12. 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…
  13. 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…
  14. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.60_slideshow.ppt
    May 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case May 2004 Too Tight Control: The Risks of Intensive Insulin Therapy Source and Credits This presentation is based on the May 2004 AHRQ WebM&M Spotlight Case in Medicine CME credit is available through the Web site See the full article at http://webmm.ahrq.gov Comm…
  15. 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…
  16. Psn-Pdf (pdf file)

    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…
  17. 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…
  18. integrationacademy.ahrq.gov/about/initiatives/opioid/grantees/north_carolina
    June 01, 2024 - An official website of the Department of Health & Human Services Search All AHRQ Sites Careers Contact Us Español FAQs Email Updates The Academy Integrating Behavioral Health & Primary Care Expand Navi…
  19. 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…
  20. Psn-Pdf (pdf file)

    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…