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www.ahrq.gov/sites/default/files/2025-05/blocker-report.pdf
January 01, 2025 - Final Progress Report: Theory to Practice: Issues and Challenges for Engineering Resilience
Project Title: Theory to Practice: Issues and Challenges for Engineering Resilience
Principal Investigator: Renaldo Blocker, Ph.D.
Team Members: Katherine Law, Ph.D., Susan Hallbeck, Ph.D., Shawna Perry, M.D., Erik
Hollnage…
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www.ahrq.gov/sites/default/files/2024-07/alpern-report.pdf
January 01, 2024 - Final Progress Report: Improving the Quality of Pediatric Emergency Care Using an Electronic Medical Record Registry
Title: Improving the Quality of Pediatric Emergency Care Using an Electronic Medical
Record Registry
Principal Investigator and Team Members:
Elizabeth R. Alpern, MD, MSCE
Organization:
Northwester…
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psnet.ahrq.gov/web-mm/missed-tb
March 03, 2010 - Missed TB
Citation Text:
FitzGerald MJ, Menzies D. Missed TB. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/web-mm/listen-family
April 15, 2015 - Listen to the Family
Citation Text:
Campbell D. Listen to the Family. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
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psnet.ahrq.gov/node/49788/psn-pdf
March 01, 2017 - Correct Treatment Plan for Incorrect Diagnosis: A
Pharmacist Intervention
March 1, 2017
Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
The Case
A 48-year…
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www.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-ape.html
September 01, 2013 - Universal ICU Decolonization: An Enhanced Protocol
Appendix E. Training and Educational Materials
Previous Page Next Page
Table of Contents
Universal ICU Decolonization: An Enhanced Protocol
Introduction and Welcome
Universal ICU Decolonization Protocol Overview
Scientific Rationale
Referenc…
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www.ahrq.gov/hai/universal-icu-decolonization/universal-icu-ape.html
September 01, 2013 - Universal ICU Decolonization: An Enhanced Protocol
Appendix E. Training and Educational Materials
Previous Page Next Page
Table of Contents
Universal ICU Decolonization: An Enhanced Protocol
Introduction and Welcome
Universal ICU Decolonization Protocol Overview
Scientific Rationale
Referenc…
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www.ahrq.gov/patients-consumers/diagnosis-treatment/treatments/btpills/btpills.html
March 01, 2023 - Blood Thinner Pills: Your Guide to Using Them Safely
The Agency for Healthcare Research and Quality offers a free booklet and a video about blood thinner medicines. Staying Active and Healthy with Blood Thinners , a 10-minute video, features easy-to-understand explanations of how blood thinners wor…
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psnet.ahrq.gov/node/33719/psn-pdf
October 01, 2011 - The Context Is the Intervention
October 1, 2011
Øvretveit J. The Context Is the Intervention. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/context-intervention
Perspective
Introduction
What we say, do, and feel are facts. We live and work in groups, in a society, and are influenced by this
context.…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.134_slideshow.ppt
September 01, 2006 - Spotlight Case September 2006
Spotlight Case September 2006
Triple Handoff
Source and Credits
This presentation is based on the September 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: Arpana Vidyarthi, MD, UCSF Sc…
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psnet.ahrq.gov/node/49614/psn-pdf
November 01, 2010 - Reconciling Records
November 1, 2010
Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/reconciling-records
The Cases
Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local
teaching hospital. When discharged, h…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.263_slideshow.ppt
March 01, 2012 - Spotlight Case July 2008
Spotlight Case
Postdischarge Follow-Up Phone Call
*
*
Source and Credits
This presentation is based on the March 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Michelle Mourad, MD, and Stephanie Rennke, MD; Divi…
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psnet.ahrq.gov/node/49661/psn-pdf
August 01, 2012 - Residual Anesthesia: Tepid Burn
August 1, 2012
Kurrek MM, Twersky RS. Residual Anesthesia: Tepid Burn. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn
The Case
A 42-year-old Filipino man presented to an outpatient surgery center for scheduled repair of an anal fistula.
The pat…
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psnet.ahrq.gov/node/49836/psn-pdf
July 01, 2018 - Primary Workaround, Secondary Complication
July 1, 2018
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
The Case
A young adult with a progressive neurological disorder presented to a hospital emerg…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.278_slideshow.ppt
September 01, 2012 - Spotlight Case July 2008
Spotlight Case
Peripheral IV in Too Long
1
2
Source and Credits
This presentation is based on the September 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Chi-Tai Fang, MD, PhD; Associate Professor, National Taiwan Uni…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pressureinjury-msmt_slides.pptx
June 02, 2025 - How To Measure Pressure Injury Rates and Prevention Practices
How To Measure
Pressure Injury Rates
and Prevention Practices
ADD Hospital Name Here
Module 5
1
Basic Quality Improvement Principle
If you can’t measure it, you can’t improve it.
2
2
Quality Improvement Principle
Pressure injury rates and preven…
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psnet.ahrq.gov/node/49756/psn-pdf
April 01, 2016 - Lost in Sign Out and Documentation
April 1, 2016
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
The Case
A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the
emergency physician, …
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/sustainability/guide.html
March 01, 2017 - Guide to Sustaining a Program To Reduce Catheter-Associated Urinary Tract Infections in Long-Term Care
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Contents
Overview
How To Use This Guide
LTC Safety Toolkit Modules
Sustainability Essentials
Leadership Commitment
…
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www.ahrq.gov/sites/default/files/2024-02/pittman-report.pdf
January 01, 2024 - Final Progress Report: Four Safety Strategies: A Symposium on Implementation
Four Safety Strategies: A Symposium on Implementation
Principal Investigator: Mary A. Pittman, Dr.P.H.
Project Team: Allan Frankel, M.D., Partners HealthCare System
Tejal Gandhi, M.D., Brigham & Women’s Hospital
Sarah Grillo
Peter…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/implement-slides.html
July 01, 2023 - Implement Teamwork and Communication for Perinatal Safety
AHRQ Safety Program for Perinatal Care
Slide 1: AHRQ Safety Program for Perinatal Care
Implement Teamwork and Communication for Perinatal Safety
Slide 2: Learning Objectives
Image: Four ascending steps show the learning objectives:
Recogn…