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www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-slides.html
December 01, 2017 - The Emergency Department & Catheter Insertions
Slide Presentation
Slide 1
The Emergency Department & Catheter Insertions
Mohamad Fakih, MD, MPH
St. John Hospital and Medical Center
Lisa Wolf, PhD, RN, CEN, FAEN
Emergency Nurses Association (ENA)
Jeremiah Schuur, MD, MHS, FACEP
Brigham and Women’s…
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www.ahrq.gov/hai/tools/surgery/modules/implementation/ssi-bundle-slides.html
October 01, 2020 - Implementing Your Surgical Site Infection Prevention Bundle: Slide Presentation
AHRQ Safety Program for Surgery
Slide 1: AHRQ Safety Program for Surgery—Implementation
Implementing Your Surgical Site Infection Prevention Bundle
Slide 2: Learning Objectives
After this session, you will be able to–
…
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www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/dx-safety-workgroup-meeting-notes-aug2025.pdf
September 01, 2025 - Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare, August 1, 2025
Federal Interagency Workgroup:
Improving Diagnostic Safety and Quality in Healthcare
August 1, 2025, 10 AM–noon
1
Workgroup Goal: Established by Senate Report 115-150. The Senate Committee on
Appropriation…
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psnet.ahrq.gov/node/33788/psn-pdf
June 01, 2015 - In Conversation With… Christine Cassel, MD
June 1, 2015
In Conversation With… Christine Cassel, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-christine-cassel-md
Editor's note: Christine Cassel, MD, is President and CEO of the National Quality Forum (NQF). Dr.
Cassel, one of the foun…
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psnet.ahrq.gov/node/49848/psn-pdf
January 01, 2019 - Inadequate Preanesthetic Evaluation, Airway Trouble
November 1, 2018
Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
The Case
Case #1:
A 34-year-old woman was scheduled for a hysteroscopy under g…
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psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
October 30, 2024 - Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration
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June 14, 2023
Innov…
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psnet.ahrq.gov/print/pdf/node/865864
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Diagnostic Error
Curated Library
Incidence of Diagnostic Errors
25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the
National Practitioner Data Bank.
Tehrani ASS, Lee HW, Mathews SC, et al. BMJ Qua…
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digital.ahrq.gov/ahrq-funded-projects/meaningful-drug-interaction-alerts
February 28, 2023 - Meaningful Drug Interaction Alerts
Project Final Report ( PDF , 323.31 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. No statement in this…
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psnet.ahrq.gov/node/49693/psn-pdf
October 01, 2013 - It's Sarah, Not Stephen!
October 1, 2013
Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/its-sarah-not-stephen
Case Objectives
Define and distinguish the terms gender identity, gender expression, and gender variance.
Delineate patient safety issues associated with transge…
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - Acute Respiratory Arrest in Pregnancy
Citation Text:
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cancer-anemia_executive.pdf
May 01, 2006 - Layout 1
Background
Anemia (deficiency of red blood cells)
occurs in 13-78 percent of patients
undergoing treatment for solid tumors and
30-40 percent of patients treated for
lymphoma. Tumor type, treatment
regimen, and history of prior cancer
therapy influence the risk and severity of
anemia. For example, among pa…
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psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
June 01, 2016 - A Seasonal Care Transition Failure
Citation Text:
Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/33596/psn-pdf
June 01, 2025 - Failure to Rescue
January 29, 2025
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/failure-rescue
Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet
primers are regularly reviewed and updated to ensure that they reflect cur…
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psnet.ahrq.gov/web-mm/managing-care-challenges-group-home-setting-staffing-adequate-unplanned-incidents
April 27, 2022 - Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents?
Citation Text:
Ordona R, Bakerjian D. Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
May 27, 2020 - Hyponatremia Secondary to Home Parenteral Nutrition Error
Citation Text:
Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
November 01, 2012 - Defensive Medicine: "Glowing" with Pain
Citation Text:
Sethi MK. Defensive Medicine: "Glowing" with Pain. 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/departure-central-line-ritual
October 13, 2018 - Departure From Central Line Ritual
Citation Text:
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/environmental-safety-or
May 19, 2015 - Environmental Safety in the OR
Citation Text:
Linkin DR, Lautenbach E. Environmental Safety in the OR . 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/web-mm/round-trip-service
April 26, 2023 - Round-Trip Service
Citation Text:
McGrath MH. Round-Trip Service. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
December 01, 2017 - Unexpected Drawbacks of Electronic Order Sets
Citation Text:
McGreevey JD. Unexpected Drawbacks of Electronic Order Sets. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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