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7341. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49542/psn-pdf
      August 21, 2007 - Copy and Paste August 21, 2007 Hersh WR. Copy and Paste. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/copy-and-paste The Case A 77-year-old woman was admitted to a teaching hospital with diarrhea and dehydration after completing her fifth cycle of chemotherapy for ovarian cancer. Her only relevant past m…

7342. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49406/psn-pdf
      June 01, 2003 - The Dangerous Detour June 1, 2003 Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dangerous-detour The Case Following an overdose of alcohol and Ativan, a 26-year-old woman was admitted to the Medicine service for observation after being placed on a 72-hour hold by…

7343. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33621/psn-pdf
      November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience November 1, 2005 Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience Perspective Health care organizations throughout the world have ide…

7344. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60168/psn-pdf
      March 25, 2020 - Right Electrocardiogram, Wrong Patient March 25, 2020 Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient The Cases Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…

7345. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
      January 01, 2020 - PowerPoint Presentation Spotlight A ʺReflexiveʺ Diagnosis in Primary Care 1 This presentation is based on the April 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John Betjemann, MD, and S. Andrew Josephson, MD, University of California, San…

7346. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49595/psn-pdf
      December 01, 2009 - "Superficial" Report Leads to "Deep" Problem December 1, 2009 Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem The Case A 35-year-old woman presented to the emergency department (ED) complaining of left foot and an…

7347. 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…

7348. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49814/psn-pdf
      December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation Mishap December 1, 2017 Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap The Case A 63-year-old man with a history of coronary…

7349. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33860/psn-pdf
      June 01, 2018 - Safety Considerations in Building a Point-of-Care Ultrasound Program June 1, 2018 Moore C. Safety Considerations in Building a Point-of-Care Ultrasound Program. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program Perspective At the American Colle…

7350. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33876/psn-pdf
      August 01, 2018 - Building a Safety Program in a Vast Health Care Network March 1, 2019 Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network Perspective Background As hospital-based health care in the United …

7351. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49850/psn-pdf
      January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia January 1, 2019 Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia The Case A 72-year-old woman with a history of severe peripheral vascular dis…

7352. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49742/psn-pdf
      September 01, 2015 - A Fumbled Handoff to Inpatient Rehab September 1, 2015 Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab The Case An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…

7353. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33687/psn-pdf
      August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health Care August 1, 2009 Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care Perspective Frontline health care providers are challen…

7354. Staffing During the COVID-19 Pandemic: A Guide for Nursing Home Leaders (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/guide-staffing-during-COVID19.pdf
      June 02, 2025 - Staffing During the COVID-19 Pandemic: A Guide for Nursing Home Leaders Staffing During the COVID-19 Pandemic: A Guide for Nursing Home Leaders Introduction This resource guide was written by and for directors of nursing, administrators, and other nursing home leaders. It outlines steps to reduce or elimi…

7355. Hospital Survey on Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.pdf
      June 02, 2025 - Hospital Survey on Patient Safety SOPS TM Hospital Survey Version: 1.0 Language: English Note • For more information on getting started, selecting a sample, determining data collection methods, establishing data collection procedures, conducting a Web-based survey, and preparing and analyz…

7356. AHRQ Works: Building Bridges Between Research and Practice (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cpi/about/impact/ahrq-works.pdf
      April 01, 2017 - AHRQ Works: Building Bridges Between Research and Practice Accelerating learning and innovation in health care delivery is what AHRQ does—every day. AHRQ tools take the “what” and translate it into the “how” by providing research-backed, practical tools that doctors and nurses can use to improve care. This doc…

7357. Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Fenton-Wilhelm-Amos (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/4-unc-webcast-fenton-wilhelm-amos.pdf
      August 15, 2019 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Fenton-Wilhelm-Amos U N C H E A L T H C A R E S Y S T E M U N C H E A L T H C A R E Culture of Safety Improvement Project UNC Medical Center 29 U N C H …

7358. SOPS® Value and Efficiency Supplemental Items for the SOPS Hospital Survey - English (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-ve-supp-item-set-08-2022.pdf
      January 01, 2022 - SOPS® Value and Efficiency Supplemental Items for the SOPS Hospital Survey - English SOPS® Value and Efficiency Supplemental Item Set for the SOPS Hospital Survey Language: English • Purpose: This supplemental item set was designed for use with the core SOPS® Hospital Survey Version 2.0 to help hospitals assess…

7359. May 2025: National Action Alliance for Patient and Workforce Safety Webinar Chat Transcript (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/implementing-cms-measure-chat-transcript.pdf
      May 01, 2025 - May 2025: National Action Alliance for Patient and Workforce Safety Webinar Chat Transcript Welcome to the May NAA National Webinar.   Stay Connected with the National Action Alliance for Patient and Workforce Safety: Subscribe to the NAA Listserv Monthly Bulletin and Email us at NationalActionAlliance@hhs.gov   …

7360. Mutual Support Two-Day Training | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/mutual/teach/two-day.html
      July 01, 2024 - Mutual Support Two-Day Training If you are teaching the Situation Monitoring Module as part of a two-day training, you should be able to perform all the activities noted below in around 90 minutes. Components you can include in this section for a two-day training include the following: Introduction and Objectiv…