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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853773/psn-pdf
    September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side. September 27, 2023 Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side The Case A first-year orthopedic surgery resident was consulted…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49864/psn-pdf
    June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout June 1, 2019 Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33746/psn-pdf
    March 01, 2013 - In Conversation With… David M. Gaba, MD March 1, 2013 In Conversation With… David M. Gaba, MD. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-david-m-gaba-md Editor's note: David M. Gaba, MD, is a Professor of Anesthesia at the Stanford University School of Medicine. An international leade…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49799/psn-pdf
    July 01, 2017 - Delayed Recognition of a Positive Blood Culture July 1, 2017 Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture The Case A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49654/psn-pdf
    June 01, 2012 - Transfer Troubles June 1, 2012 Hains IM. Transfer Troubles. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfer-troubles Case Objectives Recognize that transfer of patients between hospitals is common. Understand the frequency of errors and adverse events in the transfer of patients between hospitals. …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49669/psn-pdf
    November 01, 2012 - Transfusion Overload November 1, 2012 Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfusion-overload Case Objectives Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit below 30% are not supported by the evidence.…

  7. Synthesis Report: Methods and Results From the AHRQ Estimating Costs Research Grants | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/research-transform-primary-care/transform/cost/report.html
    October 01, 2015 - Estimating the Costs of Primary Care Transformation: A Practical Guide and Synthesis Report Synthesis Report: Methods and Results From the AHRQ Estimating Costs Research Grants Previous Page Next Page Table of Contents Estimating the Costs of Primary Care Transformation: A Practical Guide and Synthe…

  8. Synthesis Report: Methods and Results From the AHRQ Estimating Costs Research Grants | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/reports/cost-guide/synthesis-report.html
    February 01, 2017 - Estimating the Costs of Primary Care Transformation: A Practical Guide and Synthesis Report Synthesis Report: Methods and Results From the AHRQ Estimating Costs Research Grants Previous Page Next Page Table of Contents Estimating the Costs of Primary Care Transformation: A Practical Guide and Synthe…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49793/psn-pdf
    May 01, 2017 - Hemolysis Holdup May 1, 2017 Lehman CM. Hemolysis Holdup. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hemolysis-holdup The Case A 72-year-old man with congestive heart failure due to nonischemic cardiomyopathy, stage 3 chronic kidney disease, atrial fibrillation, and type 2 diabetes mellitus presented t…

  10. Pre-Intervention Survey of Hospital Staff

    hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/nm3.jsp
    July 01, 2014 - Pre-Intervention Survey of Hospital Staff An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs Email Upd…

  11. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
    June 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case June 2004 The Wrong Shot: Error Disclosure Source and Credits This presentation is based on the June 2004 AHRQ WebM&M Spotlight Case in Pediatrics CME credit is available through the Web site See the full article at http://webmm.ahrq.gov Commentary by: Thomas H. …

  12. The Wise App Trial for Improving Health Outcomes in PLWH | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/wise-app-trial-improving-health-outcomes-plwh
    January 01, 2024 - The Wise App Trial for Improving Health Outcomes in PLWH Project Final Report ( PDF , 313.22 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…

  13. Engineering Safe Practices Affinity Group | Agency for Healthcare Research and Quality

    www.ahrq.gov/action-alliance/engineering-safety-practice/index.html
    September 01, 2025 - Engineering Safe Practices Affinity Group Background  The National Action Alliance established the Engineering Safe Practices Affinity Group to make healthcare safer by design by identifying scalable opportunities for engineering safety into key healthcare practices—one of the Alliance’s five Aims. Read more …

  14. Section 5

    hcup-us.ahrq.gov/reports/factsandfigures/2008/section5_TOC.jsp
    January 01, 2008 - Section 5 An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs Email Updates …

  15. September: A Month for Increasing Awareness About Sepsis | Agency for Healthcare Research and Quality

    www.ahrq.gov/news/newsletters/e-newsletter/973.html
    September 01, 2025 - September: A Month for Increasing Awareness About Sepsis Issue Number 973 AHRQ News Now is a weekly newsletter that highlights agency research and program activities. September 3, 2025 Today’s Headlines: September: A Month for Increasing Awareness About Sepsis . Opportunities for Diagnosis and Treatment…

  16. Healthcare Cost and Utilization Project (HCUP) NEDS Notes

    hcup-us.ahrq.gov/db/vars/drg/nedsnote.jsp
    May 01, 2015 - Healthcare Cost and Utilization Project (HCUP) NEDS Notes An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQ…

  17. Information Technology in Primary Care Practice (pdf file)

    digital.ahrq.gov/sites/default/files/docs/survey/it-primary-care-practice.pdf
    June 16, 2021 - Information Technology in Primary Care Practice Information Technology in Primary Care Practice University of Washington, Seattle WA This is a questionnaire designed to be completed by nurses and physicians in an ambulatory setting. The tool includes questions to assess user's perceptions of electronic health rec…

  18. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality | PSNet

    psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
    October 01, 2004 - SPOTLIGHT CASE Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality Citation Text: Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. Rockville (MD): Agency for Healthcare Res…

  19. Patient Safety Culture and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/reports/liability/waever.html
    August 01, 2017 - Advances in Patient Safety and Medical Liability Patient Safety Culture and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary Previous Page Next Page Table of Contents Advances in Patient Safety and Medical Liability Preface Acknowledgments Prologue …

  20. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care 1 Source and Credits This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Elizabeth Gould, NP-C, COR…
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