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4901. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49413/psn-pdf
      September 01, 2003 - Did We Forget Something? September 1, 2003 Gibbs VC. Did We Forget Something? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/did-we-forget-something The Case A 76-year-old-man underwent right aorto-iliac aneurysm repair. He developed postoperative fever, initially attributed to ventilator-associated pneumo…

4902. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49473/psn-pdf
      March 01, 2005 - On O.R. Off? March 1, 2005 Leonard M. On O.R. Off? PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/or The Case An elderly man was admitted to the vascular surgery service with rest pain in his leg. Angiography demonstrated peripheral artery disease with anatomy suitable for revascularization. A consulting …

4903. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49623/psn-pdf
      March 01, 2011 - Are We Pushing Graduate Nurses Too Fast? March 1, 2011 Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast The Case A middle-aged man was admitted to the surgical intensive care unit (SICU) following a complex surgical…

4904. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49463/psn-pdf
      October 14, 2004 - Moved Too Soon October 1, 2004 Lindenauer PK. Moved Too Soon. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/moved-too-soon The Case A 67-year-old man was admitted to a general hospital ward after undergoing a laminectomy. Two hours after arriving, while the patient was still groggy from anesthesia, a nurs…

4905. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33623/psn-pdf
      December 01, 2005 - The Unintended Consequences of Florida Medical Liability Legislation December 1, 2005 Barach P. The Unintended Consequences of Florida Medical Liability Legislation. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation Perspective Quality health …

4906. Final Progress Report: Ambulatory Pediatric Patient Safety Learning Lab: Pursuing Safe Healthcare at Home (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/walsh-kirkendall-report.pdf
      January 01, 2025 - indicates that medication safety and treatment delay are critical areas in outpatient care where harm is occurring … communications between parent and clinic that took place after a psychotropic medication started or changed, occurring … errors and failure modes as well as opportunities to improve the care of our patients where it is occurring

4907. Surgical Safety: Addressing the JCAHO Goals for Reducing Wrong-site, Wrong-patient, Wrong-procedure Events (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Ludwick.pdf
      June 21, 2004 - Surgical Safety: Addressing the JCAHO Goals for Reducing Wrong-site, Wrong-patient, Wrong-procedure Events 483 Surgical Safety: Addressing the JCAHO Goals for Reducing Wrong-site, Wrong-patient, Wrong-procedure Events Sandra Ludwick Abstract Under standards set forth by the Joint Commission on Accreditatio…

4908. Guide to Sustainability Planning: Long-Term Care Facilities (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/sustainability-plan.pdf
      June 01, 2021 - Guide to Sustainability Planning: Long-Term Care Facilities AHRQ Safety Program for Improving Antibiotic Use Guide to Sustainability Planning: Long-Term Care Facilities Sustainability Planning 2 AHRQ Safety Program for Improving Antibiotic Use – Long-Term Care Introduction Johns Hopkins Medicine and NOR…

4909. Urine Culturing Stewardship in the ICU Setting Facilitator Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urine-culturing-notes.docx
      April 01, 2022 - Urine Culturing Stewardship in the ICU Setting Facilitator Notes CAUTI Module: Urine Culturing Stewardship in the ICU Setting Facilitator Guide Slide Number and Image This module, titled “Urine Culturing Stewardship in the ICU Setting” is part of the Agency for Healthcare Research and Quality’s Safety Program …

4910. Making Effective Behavior Changes Around Antibiotic Prescribing (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/behavior-change-facilitator-guide.pdf
      November 01, 2019 - Making Effective Behavior Changes Around Antibiotic Prescribing AHRQ Safety Program for Improving Antibiotic Use 1AHRQ Pub. No. 17(20)-0028-EF November 2019 AHRQ Pub. No. 17(20)-0028-EF November 2019 Making Effective Behavior Changes Around Antibiotic Prescribing Acute Care S…

4911. Final Progress Report: Patient-centered approach to reducing harm from VTE (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/rothberg-report.pdf
      January 01, 2024 - Final Progress Report: Patient-centered approach to reducing harm from VTE Title: Patient-centered approach to reducing harm from VTE Principal Investigator: Michael Rothberg, MD, MPH Team Members: Aaron Hamilton, Bo Hu, Michael Kattan, Phuc Le, Lei Kou, Jacqueline Fox Organization: Cleveland Clinic Foundation In…

4912. AHRQ_Brand_NameOnly (xls file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/sustainability/sustainability-assesment-tool.xlsx
      March 01, 2017 - Sheet1 The purpose of this tool is to support the maintenance of your AHRQ Safety Program for Long-Term Care: CAUTI program efforts and its benefits to the improvement of resident safety culture overtime. This tool will help your team identify their current state, including what’s working and what’s not working, outl…

4913. Final Progress Report: Rural Healthcare Quality Network (RHQN) – AHRQ Grant Pre-Intervention Study Results (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/huck-report.pdf
      January 01, 2024 - Final Progress Report: Rural Healthcare Quality Network (RHQN) – AHRQ Grant Pre-Intervention Study Results Rural Healthcare Quality Network (RHQN) – Agency for Healthcare Research and Quality Grant FINAL REPORT BACKGROUND Purpose of the Study The purpose of the study was to examine clinician’s attitudes and p…

4914. Final Progress Report: Preventing/Managing C. Diff for Nursing Home Residents, Admissions, and Discharges (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/phillips-report.pdf
      January 01, 2024 - Final Progress Report: Preventing/Managing C. Diff for Nursing Home Residents, Admissions, and Discharges FINAL PROGRESS REPORT Project Title: Preventing/Managing C. Diff for Nursing Home Residents, Admissions, and Discharges Principal Investigator: Charles D. Phillips, PhD, MPH, Regents Professor, Texas A&M …

4915. Optimize Briefings and Debriefings: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/implementation/opt-briefings-slides.html
      December 01, 2017 - Optimize Briefings and Debriefings: Slide Presentation AHRQ Safety Program for Surgery Slide 1: AHRQ Safety Program for Surgery—Implementation Optimize Briefings and Debriefings Slide 2: Learning Objectives Describe characteristics of effective briefings and debriefings. Present the evidence bas…

4916. Guide: Purpose and Use of CLABSI Tools | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/clabsi-tools/guide.html
      January 01, 2020 - Guide: Purpose and Use of CLABSI Tools Purpose of the Tools These tools are designed to support your efforts to implement evidence-based practices and eliminate central line-associated blood stream infections (CLABSI) in your unit. When used with the Comprehensive Unit-based Safety Program (CUSP) Toolkit, the…

4917. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49506/psn-pdf
      March 01, 2006 - The Wet Read March 1, 2006 Arenson RL. The Wet Read. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/wet-read Case Objectives Appreciate the limitations of radiology resident emergency coverage. Understand the rate of discrepancy between radiology resident preliminary reads and attending radiologists' fina…

4918. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49666/psn-pdf
      October 01, 2012 - CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure October 1, 2012 Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure Case Objectives Identify risk f…

4919. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. | PSNet
      psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
      October 28, 2020 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. Citation Text: Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…

4920. Delay in Malignancy Diagnosis Reflects Systemic Failures | PSNet
      psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
      September 25, 2019 - Delay in Malignancy Diagnosis Reflects Systemic Failures Citation Text: Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: …