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www.ahrq.gov/teamstepps-program/curriculum/intro/explain.html
July 01, 2023 - Section 2: Explanation and Value of the TeamSTEPPS Curriculum
This section contains explanations and illustrations to help you better understand and appreciate the structure and importance of the TeamSTEPPS curriculum and its key concepts. If you teach this content or want additional insights into how the mate…
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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 …
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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…
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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…
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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…
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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…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/aom-children-guide.docx
September 01, 2022 - The “Sometimes Antibiotics” Diagnoses: Acute Otitis Media in Children – Facilitator Guide
AHRQ Safety Program for Improving Antibiotic Use
1
The “Sometimes Antibiotics” Diagnoses: Acute Otitis Media in Children
Ambulatory Care
Slide Title and Commentary
Slide Number and Slide
The “Sometimes Antibiotics” Diagno…
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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…
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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, …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.140_slideshow.ppt
December 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case December 2006
Hidden Heparins: HIT Happens
Source and Credits
This presentation is based on the December 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Patrick F. Fogarty,…
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psnet.ahrq.gov/periodic-issue/periodic-issue-473
March 25, 2025 - March 5, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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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…
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psnet.ahrq.gov/node/49604/psn-pdf
June 01, 2010 - Tacit Handover, Overt Mishap
June 1, 2010
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
The Case
A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3
years earlier to treat an abdo…
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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, …
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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…
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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
…
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psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
August 01, 2009 - downside of first-order problem solving is lack of communication, which hinders real improvement from occurring … Even this meager form of second-order problem solving was rare, occurring in only 7% of the situations
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - downside of first-order problem solving is lack of communication, which hinders real improvement from occurring … Even this meager form of second-order problem solving was rare, occurring in only 7% of the situations
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effectivehealthcare.ahrq.gov/products/nephropathy-contrast-induced/research-protocol
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www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/syphilis-infection-pregnant-persons
November 19, 2024 - Share to Facebook
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in progress
Draft Recommendation Statement
Syphilis Infection During Pregnancy: Screening
November 19, 2024
Recommendations made by the USPSTF are independent of the U.S. …