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  1. Sustainability Module | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/slides.html
    October 01, 2020 - Sustainability Module Slide 1: Sustainability Module Sustainability Module Slide 2: Learning Objectives Image: Define sustainability. Understand the link between sustainability and spread. Create and implement a sustainability plan. Establish a sustainability measurement plan. Learn from examples …

  2. Best Practices in the Diagnosis and Treatment Hospital-Acquired Pneumonia (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/HAP-facilitator-guide.pdf
    November 01, 2019 - Best Practices in the Diagnosis and Treatment Hospital-Acquired Pneumonia AHRQ Safety Program for Improving Antibiotic Use 1 AHRQ Pub. No. 17(20)-0028-EF November 2019 Best Practices in the Diagnosis and Treatment Hospital-Acquired Pneumonia Acute Care Slide Title and Commentary Slide N…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49592/psn-pdf
    October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49466/psn-pdf
    October 14, 2004 - Hard to Swallow October 1, 2004 Driver J. Hard to Swallow. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/hard-swallow The Case An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic attack (TIA) and respiratory difficulties. The nurses noted that the patient, …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49607/psn-pdf
    August 01, 2010 - Missed Patient Assignment: Is Anyone There? August 1, 2010 Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There? PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there The Case In one hospital, nurses' patient assignments were communicated by listing the…

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

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
    January 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case January 2008 How Do Providers Recover from Errors? Source and Credits This presentation is based on the January 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Colin P. West, MD, PhD, Mayo Clini…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49452/psn-pdf
    July 01, 2004 - Allergy to Holter July 1, 2004 Williams M. Allergy to Holter. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/allergy-holter The Case A 52-year-old man was admitted for palpitations and chest pain. As part of the evaluation, on hospital day 4 the patient was sent to the cardiac clinic to start a continuous …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49493/psn-pdf
    November 01, 2005 - Infused, Not Ingested November 1, 2005 Foley M. Infused, Not Ingested. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/infused-not-ingested The Case A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering contrast, an unfamiliar task for this particular nurse. Rathe…

  9. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.317_slideshow.ppt
    March 01, 2014 - PowerPoint Presentation Spotlight Case Tough Call: Addressing Errors From Previous Providers 1 This presentation is based on the March 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: William Martinez, MD, MS, Assistant Professor of Medicine, …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49784/psn-pdf
    February 01, 2017 - Safeguarding Diagnostic Testing at the Point of Care February 1, 2017 Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care The Case A 23-year-old woman presented to the family medicine clinic for…

  11. Air on the Side of Caution | PSNet

    psnet.ahrq.gov/web-mm/air-side-caution
    April 21, 2015 - Air on the Side of Caution Citation Text: Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…

  12. Lethal Vertigo | PSNet

    psnet.ahrq.gov/web-mm/lethal-vertigo
    September 20, 2011 - Lethal Vertigo Citation Text: Furman JM. Lethal Vertigo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  13. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room | PSNet

    psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
    February 01, 2019 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room Citation Text: Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. Rockville (MD): Agency for H…

  14. Outbreak | PSNet

    psnet.ahrq.gov/web-mm/outbreak
    January 29, 2015 - Outbreak Citation Text: Rothman R, Stapleton S. Outbreak. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  15. Miscommunication in the OR Leads to Anticoagulation Mishap | PSNet

    psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
    May 08, 2019 - Miscommunication in the OR Leads to Anticoagulation Mishap Citation Text: Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Forma…

  16. An Easily Forgotten Tube | PSNet

    psnet.ahrq.gov/web-mm/easily-forgotten-tube
    June 01, 2016 - An Easily Forgotten Tube Citation Text: Ousey K. An Easily Forgotten Tube. 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 XML EndNote 7 XML Endnote tagged Pub…

  17. Hospital-, Health Care-, and Community-Acquired MRSA: Estimates From California Hospitals, 2013 #212

    hcup-us.ahrq.gov/reports/statbriefs/sb212-MRSA-Hospital-Stays-California-2013.jsp
    October 01, 2016 - Patients with multiple MRSA admissions were identified as those with two or more hospitalizations occurring

  18. Patient Safety in Office-Based Care Settings | PSNet

    psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
    January 31, 2024 - They found that such deviations were common, occurring in 70% of reviewed cases.

  19. Recommendation: Folic Acid Supplementation to Prevent Neural Tube Defects: Preventive Medication | United States Preventive Services Taskforce

    www.uspreventiveservicestaskforce.org/uspstf/recommendation/folic-acid-for-the-prevention-of-neural-tube-defects-preventive-medication
    August 01, 2023 - Based on comments, the USPSTF also included information on naturally occurring sources of folate.

  20. Ambulatory Computerized Provider Order Entry (CPOE) (pdf file)

    digital.ahrq.gov/sites/default/files/docs/lesson/08-0063-ef-ambulatory-cpoe.pdf
    May 01, 2008 - Both grantees expressed that while they were pleased to see the improvements occurring in health care
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