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  1. "Do You Want Everything Done?": Clarifying Code Status | PSNet

    psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
    March 27, 2024 - SPOTLIGHT CASE "Do You Want Everything Done?": Clarifying Code Status Citation Text: Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. …

  2. A Room Without Orders | PSNet

    psnet.ahrq.gov/web-mm/room-without-orders
    September 01, 2011 - SPOTLIGHT CASE A Room Without Orders Citation Text: Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72516/psn-pdf
    November 25, 2020 - Premature Closure: Was It Just Syncope? November 25, 2020 Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…

  4. In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
    August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD August 1, 2016  Also Read an Essay Citation Text: In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Heal…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33804/psn-pdf
    March 03, 2016 - In Conversation With… Paul McGann, MD March 1, 2016 In Conversation With… Paul McGann, MD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-paul-mcgann-md Editor's note: Dr. McGann is the Chief Medical Officer for Quality Improvement at the Centers for Medicare & Medicaid Services (CMS). He…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33789/psn-pdf
    August 01, 2015 - In Conversation With… Robert M. Wachter, MD August 1, 2015 In Conversation With… Robert M. Wachter, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md Editor's note: Dr. Wachter is Professor and the Interim Chairman of the Department of Medicine at UCSF, where he also …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49415/psn-pdf
    September 01, 2003 - Intubation Mishap September 1, 2003 Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/intubation-mishap Case Objectives To understand and apply a structured method of human factors case analysis To describe the key components of effective teamwork To understand the imp…

  8. 4. How do we implement best practices in our organization? | Agency for Healthcare Research and Quality

    www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu4.html
    October 01, 2014 - Preventing Pressure Ulcers in Hospitals 4. How do we implement best practices in our organization? Previous Page Next Page Table of Contents Preventing Pressure Ulcers in Hospitals Overview Key Subject Area Index 1. Are we ready for this change? 2. How will we manage change? 3. What are th…

  9. Despite Clues, Failed to Rescue | PSNet

    psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
    August 02, 2015 - SPOTLIGHT CASE Despite Clues, Failed to Rescue Citation Text: Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndN…

  10. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care | PSNet

    psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
    June 28, 2023 - SPOTLIGHT CASE A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care Citation Text: Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…

  11. In Conversation With… Paul McGann, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
    July 10, 2024 - In Conversation With… Paul McGann, MD March 1, 2016  Citation Text: In Conversation With… Paul McGann, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: …

  12. Final Progress Report: Immersive Simulation for Design and Evaluation of an Emergency Department IT System (pdf file)

    www.ahrq.gov/sites/default/files/2025-05/bisantz-report.pdf
    January 01, 2025 - Final Progress Report: Immersive Simulation for Design and Evaluation of an Emergency Department IT System Immersive Simulation for Design and Evaluation of an Emergency Department IT System Principal Investigator: Ann Bisantz, PhD1 Co-Investigators: Rollin J. Terry Fairbanks, MD1, 2,5 Li Lin, PhD1 A. Zachary He…

  13. Spotlight

    psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
    January 01, 2025 - Spotlight Spotlight Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations  1 Source and Credits This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Samantha Brown…

  14. 4. How do we implement best practices in our organization? | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu4.html
    October 01, 2014 - Preventing Pressure Ulcers in Hospitals 4. How do we implement best practices in our organization? Previous Page Next Page Table of Contents Preventing Pressure Ulcers in Hospitals Overview Key Subject Area Index 1. Are we ready for this change? 2. How will we manage change? 3. What are th…

  15. Evaluation Highlight No. 7: How are CHIPRA quality demonstration States designing and implementing caregiver peer support programs? (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight07.pdf
    September 08, 2015 - Evaluation Highlight No. 7: How are CHIPRA quality demonstration States designing and implementing caregiver peer support programs? The CHIPRA Quality Demonstration Grant Program In February 2010, the Centers for Medicare & Medicaid Services (CMS) awarded 10 grants, funding 18 States, to improve the quality of h…

  16. Too Many Cooks in the Kitchen | PSNet

    psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
    March 07, 2018 - SPOTLIGHT CASE Too Many Cooks in the Kitchen Citation Text: Dutton RP. Too Many Cooks in the Kitchen. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX EndNote X…

  17. Physician Event Reporting: Training the Next Generation of Physicians (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
    May 01, 2003 - Physician Event Reporting: Training the Next Generation of Physicians 353 Physician Event Reporting: Training the Next Generation of Physicians Quang-Tuyen Nguyen, Joanna Weinberg, Lee H. Hilborne Abstract Physician reporting of adverse events and unsafe situations remains extremely low, despite the increa…

  18. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_intraoperative_awareness_during_rhinoplasty_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Intraoperative Awareness during Rhinoplasty 1 Source and Credits This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Christian Bohringer MBBS and Jaijeet Toor MD AHRQ WebM&M Edit…

  19. AHRQ's Safety Program for Nursing Homes: On-Time Falls Prevention Training (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallspximpl-handouts.pdf
    June 02, 2025 - Facilitator: Can we spend a few minutes talking about our fall prevention plan and discuss strengths

  20. FRN 30: Outpatient Case Management for Adults With Medical Illnesses and Complex Care Needs: Future Research Needs (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/case-management-future_research.pdf
    June 01, 2015 - Each Webinar lasted approximately 90 minutes and consisted of approximately the same content, though … The questionnaire will take approximately 15-30 minutes to complete and will be ready approximately … If a second round of ranking is required, it will take about 5-10 minutes of your time.
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