-
psnet.ahrq.gov/node/72693/psn-pdf
January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room
– Mixing Up the Ampules
January 29, 2021
Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
The Case
A…
-
psnet.ahrq.gov/node/50842/psn-pdf
January 29, 2020 - Patient Identification Errors: A Systems Challenge
January 29, 2020
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
The Cases
The following four events involving five patients all involved…
-
psnet.ahrq.gov/node/49407/psn-pdf
July 01, 2003 - Bleeding Risk
July 1, 2003
Crowther MA. Bleeding Risk. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/bleeding-risk
The Case
A frail 78-year-old woman fell at home and fractured her left hip. Her past medical history included atrial
fibrillation, hypertension, coronary artery disease, and stroke. The surgi…
-
digital.ahrq.gov/ahrq-funded-projects/scaling-equipped-clinical-decision-support
January 01, 2024 - Scaling E.Q.U.I.P.P.E.D. Clinical Decision Support
Project Final Report ( PDF , 624.72 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No s…
-
psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
August 06, 2014 - Delayed Clozapine Prescription in an Elderly Man With Dementia
Citation Text:
Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Cita…
-
www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/techdocrpt-appd.pdf
January 01, 2019 - Comparative Health System Performance Initiative: Compendium of U.S. Health Systems, 2016, Technical Documentation-Appendix D
Comparative Health System Performance Initiative:
Compendium of U.S. Health Systems, 2016, Technical
Documentation
Prepared for:
Agency for Healthcare Research and Quality
U.S. Depar…
-
www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions-2009
April 15, 2009 - Share to Facebook
Share to X
Share to WhatsApp
Share to Email
Print
archived
Final Recommendation Statement
Tobacco Use in Adults and Pregnant Women: Counseling and Interventions
April 15, 2009
Recommendations made by the USPSTF are i…
-
psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - Annual Perspective
Handoffs and Transitions
Niraj Sehgal, MD, MPH | January 22, 2014
View more articles from the same authors.
Citation Text:
Sehgal NL. Handoffs and Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
-
hcup-us.ahrq.gov/reports/statbriefs/sb87.pdf
March 01, 2010 - from long-term care facility indicates the patient was admitted from a long-
term facility such as a nursing … home. … transfers (including skilled nursing facility, intermediate care, and another type of facility
such as a nursing … home), home health care, against medical advice (AMA), or died in the
hospital.
-
digital.ahrq.gov/sites/default/files/docs/patient-centered-care-transcript-033011.pdf
June 16, 2021 - PUTTING THE PATIENT BACK IN PATIENT-CENTERED CARE MARCH 30, 2011
1
PUTTING THE PATIENT BACK IN PATIENT-CENTERED CARE
MARCH 30, 2011
______________________________________________________________________________
COLLIN: Hello, and welcome to the AHRQ webcast. This is on the topic of the National Web-
…
-
psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - SPOTLIGHT CASE
Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture
Citation Text:
Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.. PSNet [internet]. Rockville (MD): Agency fo…
-
psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - SPOTLIGHT CASE
A Lot of Pain (Medications)
Citation Text:
Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XM…
-
psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
February 26, 2025 - In Conversation With… J. Bryan Sexton, PhD, MA
August 1, 2013
Citation Text:
In Conversation With… J. Bryan Sexton, PhD, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
Copy Citati…
-
psnet.ahrq.gov/print/pdf/node/848754
January 01, 2025 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Implementation of Patient Safety Projects
Curated Library
Foundations
Leading change: why transformation efforts fail.
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
Kotter, a professor at Harvard Business School, outlines the eight stages …
-
psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
November 25, 2020 - Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.
Citation Text:
Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
-
psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - The Impact of Communication on Medication Errors
March 15, 2021
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors
The Case
A 93-year-old man with a history of chronic systolic heart failure…
-
www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-5-working-with-safety-net-practices.pdf
September 01, 2015 - Primary Care Practice Facilitation Curriculum Module 5: Special Considerations When Working With Safety Net Practices
Agency for Healthcare Research and Quality
Advancing Excellence in Health Care www.ahrq.gov
Primary Care
Practice Facilitation
Curriculum
Module 5: Special Considerations
When Working…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/national_pcep_meeting_white_paper.docx
May 05, 2014 - The National Primary Care Extension Program: Next Steps
A White Paper based upon the Proceedings of the National Primary Care Extension Program Meeting in Washington, DC Feb 21, 2014
Executive Summary
The Primary Care Extension Program (PCEP) is a strategy to improve community health by helping primary care practices a…
-
hcup-us.ahrq.gov/db/nation/nis/reports/NIS_2012_Redesign_report.jsp
January 01, 2012 - HCUP SID File Compositions" that the Illinois SID file excluded stays in skilled nursing facilities or nursing … homes attached to a hospital, whereas stays in other specialty units within the hospital (e.g., psychiatric
-
www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamilyref.html
April 01, 2020 - Guide to Patient and Family Engagement
References
Previous Page Next Page
Table of Contents
Guide to Patient and Family Engagement
Executive Summary
Introduction
Methods
Findings
Implications for the Guide
Summary and Discussion
Next Steps
References
Appendix A: Draft Key Informant…