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psnet.ahrq.gov/node/49612/psn-pdf
November 01, 2010 - Treatment Challenges After Discharge
November 1, 2010
Coffey C. Treatment Challenges After Discharge. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
Case Objectives
Understand types and frequencies of adverse events occurring between patient discharge from the
hospital …
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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - Failure to Latch
September 1, 2008
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/failure-latch
The Case
The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to
breastfeeding exclusively for 6 months. However, early br…
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psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - Medical Devices in the "Wild"
Citation Text:
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
February 26, 2025 - In Conversation With… Erik Hollnagel, PhD
June 1, 2019
Citation Text:
In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Forma…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apv2b.html
June 01, 2010 - Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services
Appendix V (continued)
Previous Page Next Page
Table of Contents
Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services
Executive Summary
Introduction and Scan Methodology
E…
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effectivehealthcare.ahrq.gov/sites/default/files/santa_eccs2012.pdf
February 01, 2013 - Santa_ECCS2012
Slide 1: Communicating
Information About Overuse to Consumers
John Santa, M.D., M.P.H.
Director, Health
Ratings
Center
Consumer Reports, Yonkers, New York
Slide 2: Consumer Reports
in Context
• Consumers choose/pu…
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psnet.ahrq.gov/node/49869/psn-pdf
July 02, 2019 - Failure to Rescue the Mother
July 2, 2019
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/failure-rescue-mother
The Case
A 27-year-old woman, G5 P2 A2, was first admitted to the hospital at 25 weeks of pregnancy for vaginal
bleeding. An …
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psnet.ahrq.gov/node/49848/psn-pdf
January 01, 2019 - Inadequate Preanesthetic Evaluation, Airway Trouble
November 1, 2018
Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
The Case
Case #1:
A 34-year-old woman was scheduled for a hysteroscopy under g…
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psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
January 01, 2016 - Are You Mrs. A? An Issue of Identification Over Telephone
Citation Text:
Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module2/module2-obtaining-organizational-buy-in-support.pptx
August 14, 2015 - Module 2: Communication and Optimal Resolution (CANDOR) Toolkit Module 2: Obtaining Organizational Buy-in and Support
Communication and Optimal Resolution
(CANDOR)
Toolkit
Module 2: Obtaining Organizational
Buy-in and Support
Module 2 of the CANDOR Toolkit describes the importance of obtaining organizational supp…
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psnet.ahrq.gov/node/49440/psn-pdf
March 01, 2004 - Autopsy Revelation
March 1, 2004
Shojania KG. Autopsy Revelation. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/autopsy-revelation
The Case
A 45-year-old male with development delay presented to the emergency department with acute abdominal
pain. His mother, who was his main caregiver, accompanied him. Th…
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psnet.ahrq.gov/node/49451/psn-pdf
June 01, 2004 - The Result Stopped Here
June 1, 2004
Astion ML. The Result Stopped Here. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/result-stopped-here
The Case
A 91-year-old female was transferred to a hospital-based skilled nursing unit from the acute care hospital
for continued wound care and intravenous (IV) antib…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/assess-resident-UTI-facilitator-guide.docx
June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use
1
Assessment of the Resident With a
Suspected Urinary Tract Infection
Long-Term Care
Slide Title and Commentary
Slide Number and Slide
Assessment of the Resident With a Suspected Urinary Tract Infection
Long-Term Care
SAY:
Welcome to the presentation titled, “A…
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psnet.ahrq.gov/node/33758/psn-pdf
December 01, 2013 - In Conversation With… Hardeep Singh, MD, MPH
December 1, 2013
In Conversation With… Hardeep Singh, MD, MPH. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
Editor's note: Hardeep Singh, MD, MPH, is Chief of the Health Policy, Quality and Informatics Program at
the Hous…
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psnet.ahrq.gov/node/49787/psn-pdf
March 01, 2017 - Diagnosing a Missed Diagnosis
March 1, 2017
Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
The Case
A 57-year old woman was admitted to the hospital with cough, slurred speech, confusion, and
disorientation. She was taking mod…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/measuredesc-dailyearlymobility-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Measure Descriptions for Daily Early Mobility
SAY:
In this module, you will learn about the data measures you will use to evaluate early mobility process and outcome measures in your unit.
Slide 1
…
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meps.ahrq.gov/data_files/publications/st561/stat561.shtml
May 01, 2025 - Expenditures for Key Diet-Related Health Conditions, 2021-2022
Skip to main content
An official website of the Department of Health & Human Services
More
Back
Searc…
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psnet.ahrq.gov/node/33596/psn-pdf
June 01, 2025 - Failure to Rescue
January 29, 2025
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/failure-rescue
Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet
primers are regularly reviewed and updated to ensure that they reflect cur…
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/index.html
October 01, 2020 - What We Learned
The CHIPRA quality demonstration States are pursuing innovative strategies to improve health care for children.
Learn about the CHIPRA quality demonstration States' strategies, lessons learned, and outcomes from these National Evaluation products:
Final Summary
Final Project Report
Spe…
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www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/part2.html
June 01, 2018 - Chartbook on Health Care for Blacks
Part 2: Trends in Priorities of the Heckler Report
Previous Page Next Page
Table of Contents
Chartbook on Health Care for Blacks
Health Care for Blacks
Acknowledgments
Part 1: Overviews of the Report and the Black Population
Part 2: Trends in Priorities of…