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psnet.ahrq.gov/node/49524/psn-pdf
November 01, 2006 - Secured But Not Always Safe
November 1, 2006
Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/secured-not-always-safe
The Case
An 84-year-old healthy woman underwent an elective left total knee replacement for degenerative
osteoarthritis. She received spinal …
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integrationacademy.ahrq.gov/about/initiatives/opioid/grantees/oklahoma
April 01, 2023 - An official website of the Department of Health & Human Services
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Careers
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Integrating Behavioral Health & Primary Care
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-2.html
August 01, 2023 - Pediatric Diagnostic Safety: State of the Science and Future Directions
Challenges in Approaching Diagnostic Safety Unique to Children
Previous Page Next Page
Table of Contents
Pediatric Diagnostic Safety: State of the Science and Future Directions
Introduction
Challenges in Approaching Diagnost…
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psnet.ahrq.gov/node/73905/psn-pdf
October 06, 2021 - Health Equity and Maternal Health
October 6, 2021
Tully K, Stuebe AM, Gibson A, et al. Health Equity and Maternal Health. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/health-equity-and-maternal-health
Redefining Maternal Safety
Maternal safety refers to the safety of a person during pregnancy, childb…
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www.ahrq.gov/cahps/news-and-events/events/2020-meeting-summary.html
December 01, 2020 - Advancing Methods of Implementing and Evaluating Patient Experience Improvement Using CAHPS® Surveys: Summary of Presentations
Summary of Meeting Highlights
On October 7, 2020, the Agency for Healthcare Research and Quality (AHRQ) convened an invitation-only research meeting to discuss improving patient exper…
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www.ahrq.gov/ncepcr/reports/2025-annual-report/references.html
August 01, 2025 - AHRQ’s Investments in Primary Care Research for 2023 and 2024
References
Previous Page
Table of Contents
AHRQ’s Investments in Primary Care Research for 2023 and 2024
Acknowledgements and Authors
Message from the Director of AHRQ’s National Center for Excellence in Primary Care Research
Ab…
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www.ahrq.gov/sites/default/files/2025-04/castro-report.pdf
January 01, 2025 - Final Progress Report: Diagnostic Error in Medicine Conference 2020-2022
Title Page – Final Progress Report
Title: Diagnostic Error in Medicine Conference 2020-2022
Principal Investigator: Gerry Castro, PhD, MPH
Team Members:
2022 Conference Chairs, Co-chairs and Planning Commitee members
Andrew Olson…
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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/too-tight-control
March 20, 2013 - SPOTLIGHT CASE
Too Tight Control
Citation Text:
Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/837659/psn-pdf
July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging
July 8, 2022
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
The Cases
Case #1: A 42-year-old woman admitted with…
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psnet.ahrq.gov/node/33801/psn-pdf
February 01, 2016 - In Conversation With…Christine A. Sinsky, MD
February 1, 2016
In Conversation With…Christine A. Sinsky, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md
Editor's note: Christine A. Sinsky, MD, is the Vice President for Professional Satisfaction at the American
Me…
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psnet.ahrq.gov/node/49828/psn-pdf
May 01, 2018 - Out of Sight, Out of Mind: Out-of-Office Test Result
Management
May 1, 2018
Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
Case Objectives
Recognize the general responsibilities of…
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psnet.ahrq.gov/node/49819/psn-pdf
February 01, 2018 - Signout Fallout
February 1, 2018
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/signout-fallout
Case Objectives
Understand the role of communication failures in medical errors and preventable adverse events.
Review the evidence in support of handoff improvement pr…
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psnet.ahrq.gov/node/60745/psn-pdf
October 01, 2020 - Multiple High-Risk Events Involving Workflow for Wasting
of Medications Used by Anesthesia
July 29, 2020
Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications
Used by Anesthesia. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-high-risk-events-involvi…
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psnet.ahrq.gov/node/49549/psn-pdf
December 06, 2007 - Elopement
December 1, 2007
Gerardi D. Elopement. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/elopement
Case Objectives
Define elopement and differentiate it from wandering and leaving against medical advice.
Identify leading contributors to elopement events.
Describe strategies for preventing elopement…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-icu-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Early Mobility in the Intensive Care Unit
SAY:
In this slide set, we will look at the benefits, safety, feasibility, and sustainability of early mobility. Many hospitals and intensive care units or IC…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/urine-culturing/antibiotic-stewardship/abx-stewardship-part1.pptx
March 01, 2017 - Antibiotic Stewardship Slides, Part 1: Hand Hygiene
How To Avoid the Harms of
Antibiotic Overuse
Training Module 4
AHRQ Pub. No. 16(17)-0003-21-EF
March 2017
AHRQ Safety Program for Long-term Care: HAIs/CAUTI
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
AHRQ SAFETY PROGRAM FOR LONG-TERM CARE: HAIs/CAUTI
…
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www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/current-processes-refining-evidence-based-recommendation-development
January 01, 2014 - Current Processes: Refining Evidence-based Recommendation Development
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Table of Contents
Preface
Introduction
Types of Recommendations
Types of Evidence Reviews
Co…
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psnet.ahrq.gov/node/33702/psn-pdf
November 01, 2010 - In Conversation with...Patrick S. Romano, MD, MPH
November 1, 2010
In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
Editor's note: Patrick S. Romano, MD, MPH, is Professor of Medicine and Pediatrics at the Universit…
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - SPOTLIGHT CASE
The ECG Is Not Normal
Citation Text:
Zuger A. The ECG Is Not Normal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…