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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Tacit Handover, Overt Mishap
Citation Text:
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/more-treatment-better-care
August 11, 2021 - More Treatment—Better Care?
Citation Text:
Redberg R. More Treatment—Better Care?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
October 26, 2022 - Diagnosing a Missed Diagnosis
Citation Text:
Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/reaction-dye
March 01, 2007 - Reaction to Dye
Citation Text:
Cohan R. Reaction to Dye. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
January 01, 2019 - Spotlight
Missed Opportunities for Suicide
Risk Assessment
Source and Credits
• This presentation is based on the November 2019 AHRQ WebM&M
Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Glen Xiong, MD & Debra Kahn, MD
○ Editors in Chief, AHRQ We…
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psnet.ahrq.gov/node/49570/psn-pdf
October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure?
October 1, 2008
Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
Case Objectives
Understand the complementary abilities of an electronic health record a…
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www.ahrq.gov/sites/default/files/2024-11/devita-report.pdf
January 01, 2024 - Final Progress Report: METs: Preventing Patient Crisies; Protecting Patients in Crisis
AHRQ Final Report
Title of Project: METs: Preventing Patient Crisies; Protecting Patients in Crisis
AHRQ grant: 1 R13 HS 15757-01
Awarded May, 2005.
Dates of project: May 2005-May 2006.
Date of Conference: June 25 and 26, 2005.
…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-indications-notes.docx
April 01, 2022 - Indwelling Urinary Catheter Indications Facilitator Notes
CAUTI Module:
Indwelling Urinary Catheter Indications
Facilitator Guide
Slide Number and Image
This module, titled “Indwelling Urinary Catheter Indications” is part of the Agency for Healthcare Research and Quality’s Safety Program for Intensive Care Uni…
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www.ahrq.gov/hai/tools/mvp/modules/technical/intro-daily-care-facguide.html
February 01, 2017 - Introduction to Daily Care Processes: Evidence Behind Spontaneous Awakening Trials, Spontaneous Breathing Trials, and Head of Bed Elevation: Facilitator Guide
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: Introduction to Daily Care Processes: Evidence Behind Spontaneous Awakening Trials, S…
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psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx
Spotlight
Challenging Case of Multiple Suicide Attempts in a
Complex Patient with Psychiatric Comorbidities
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://…
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psnet.ahrq.gov/innovations
February 26, 2025 - Innovations
The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4b_pdi02-pressureulcer-bestpractices.pdf
January 01, 2012 - Selected Best Practices and Suggestions for Improvement
Pediatric Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4b
Selected Best Practices and Suggestions for Improvement
PDI 02: Pressure Ulcer
Why focus on pressure ulcers in children?
• Although childre…
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www.ahrq.gov/prevention/chronic-care/decision/mcc/mccpublications.html
May 01, 2014 - AHRQ Multiple Chronic Conditions Research Network Publications
This bibliography includes publications resulting from R18, R21 and R24 AHRQ Multiple Chronic Conditions Research Network grants funded between 2008 and 2010. The publications listed below are those that were published or in press as of August 2013.…
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psnet.ahrq.gov/node/49501/psn-pdf
February 03, 2006 - Lost in Transition
February 1, 2006
Beach C. Lost in Transition. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/lost-transition
Case Objectives
Provide an overview of transitions in continuously operating industries
Review cognitive error
Describe the complex dynamics of transitions in emergency care
Pro…
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psnet.ahrq.gov/node/49567/psn-pdf
September 01, 2008 - Empiric Steroids: the Good, the Bad, and the Ugly
September 1, 2008
Harris ED. Empiric Steroids: the Good, the Bad, and the Ugly. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
Case Objectives
Describe appropriate indications for use of steroids.
Appreciate contraindicati…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2017_cg_cahps_chartbook.pdf
January 01, 2017 - 2017 CAHPS Clinician & Group Survey Database Chartbook
THE CAHPS DATABASE
CAHPS Clinician & Group Survey Database
2017 Chartbook
The content of this document may be used and reprinted without permission except for the following: Federal
Government logos, items noted with specific restrictions, and thos…
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effectivehealthcare.ahrq.gov/sites/default/files/clifford.pdf
May 29, 2025 - PATIENTSLIKEME
INNOVATIONS CONFERENCE -- PATIENTSLIKEME
SPEAKER: DAVE CLIFFORD,
HEAD OF PUBLIC HEALTH AND GOVERNMENT AFFAIRS,
PATIENTSLIKEME
CLIFFORD: Hi. I'm Dave Clifford from PatientsLikeMe. I'm gonna talk
about patient value in online communities a bit from our experie…
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psnet.ahrq.gov/web-mm/discharge-fumbles
September 09, 2009 - SPOTLIGHT CASE
Discharge Fumbles
Citation Text:
Forster AJ. Discharge Fumbles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4p_combo_pdi02-pressureulcer-bestpractices.pdf
January 01, 2012 - Selected Best Practices and Suggestions for Improvement
Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4p
Selected Best Practices and Suggestions for Improvement
PDI 02: Pressure Ulcer
Why focus on pressure ulcers in children?
• Although children are typi…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patient-role-references.html
September 01, 2024 - The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception Toward Co-Design
References
Previous Page
Table of Contents
The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception Toward Co-Design
Introduction
The History of Patient Roles
Impact of Dis…