-
psnet.ahrq.gov/node/49442/psn-pdf
May 01, 2004 - Missed TB
May 1, 2004
FitzGerald MJ, Menzies D. Missed TB. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/missed-tb
The Case
A 38-year-old white female with no past medical history presented to the hospital with fevers, respiratory
failure, and bilateral pulmonary infiltrates. She was treated empirically w…
-
psnet.ahrq.gov/node/850362/psn-pdf
June 14, 2023 - Home Medications Contribute to a Unique Opportunity for
Error on Discharge from the Hospital
June 14, 2023
Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from
the Hospital. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opp…
-
www.ahrq.gov/hai/pfp/haccost2017-discuss.html
November 01, 2017 - Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions
Discussion
Previous Page Next Page
Table of Contents
Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions
Discussio…
-
psnet.ahrq.gov/node/73412/psn-pdf
August 01, 2022 - “Behavioral Health Vital Signs” Initiative Increases Patient
Education and Disclosure about Interpersonal Violence
(IPV)
June 30, 2021
https://psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and-
disclosure
Summary
The Behavioral Health Vital Signs (BHVS) screener i…
-
psnet.ahrq.gov/node/49740/psn-pdf
August 21, 2015 - Baffled by Botulinum Toxin
August 21, 2015
Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
The Case
A 5-year-old boy with a history of transverse myelitis with resultant spasticity of both lower extremities, gait
abnormalities, neurogeni…
-
psnet.ahrq.gov/node/49595/psn-pdf
December 01, 2009 - "Superficial" Report Leads to "Deep" Problem
December 1, 2009
Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
The Case
A 35-year-old woman presented to the emergency department (ED) complaining of left foot and an…
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
June 02, 2025 - Hospital Survey on Patient Safety
SOPS
TM
Hospital Survey
Version: 1.0
Language: English
Note
• For more information on getting started, selecting a sample, determining data collection methods,
establishing data collection procedures, conducting a Web-based survey, and preparing and
analyzing data, and prod…
-
psnet.ahrq.gov/node/49438/psn-pdf
March 05, 2004 - OR Peeping
March 1, 2004
Mackenzie CF. OR Peeping. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/or-peeping
The Case
A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete
spontaneous abortion (miscarriage).
At this community hospital, a new operating room (OR) su…
-
psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
January 01, 2020 - Spotlight
Spotlight
Inpatient Stroke Management in a Patient
with Type 1 Diabetes and Home Insulin
Pump
Source and Credits
• This presentation is based on the October 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Berit B…
-
psnet.ahrq.gov/node/33876/psn-pdf
August 01, 2018 - Building a Safety Program in a Vast Health Care Network
March 1, 2019
Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
Perspective
Background
As hospital-based health care in the United …
-
psnet.ahrq.gov/node/49659/psn-pdf
July 01, 2012 - Sloppy and Paste
July 1, 2012
Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/sloppy-and-paste
The Case
A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new
onset chest pain. The ED physician reviewed the patient's electronic me…
-
www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-slides.html
December 01, 2017 - The Science of Improving Patient Safety and Identifying Defects: Slide Presentation
AHRQ Safety Program for Surgery
Slide 1: AHRQ Safety Program for Surgery—Onboarding
The Science of Improving Patient Safety and Identifying Defects
Slide 2: Learning Objectives
After this session, you will be able to…
-
psnet.ahrq.gov/node/73643/psn-pdf
August 01, 2022 - ECHO-Care Transitions Successfully Reduces Patient
Readmissions from Skilled Nursing Facilities, Reduces
Length of Stay
August 25, 2021
https://psnet.ahrq.gov/innovation/echo-care-transitions-successfully-reduces-patient-readmissions-skilled-
nursing
Summary
ECHO-Care Transitions (ECHO-CT) intends to ensure cont…
-
www.ahrq.gov/research/findings/final-reports/ptflow/section6.html
July 01, 2018 - Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals
Section 6. Facilitating Change and Anticipating Challenges
Previous Page Next Page
Table of Contents
Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals
Acknowledgments
E…
-
psnet.ahrq.gov/node/49617/psn-pdf
January 01, 2011 - Failure to Reevaluate
December 1, 2010
Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/failure-reevaluate
The Case
A 61-year-old woman receiving palliative chemotherapy for non–small-cell lung cancer at a community
hospital developed methicillin-resistant staphylococc…
-
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-slides.html
July 01, 2023 - Monitoring for Perinatal Safety: Electronic Fetal Monitoring: Slide Presentation
AHRQ Safety Program for Perinatal Care
Slide 1: Monitoring for Perinatal Safety: Electronic Fetal Monitoring
Monitoring for Perinatal Safety: Electronic Fetal Monitoring
Slide 2: Learning Objectives
Image: This slide sh…
-
psnet.ahrq.gov/node/49587/psn-pdf
May 01, 2009 - Missing Trauma
May 1, 2009
Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/missing-trauma
The Case
A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a
few minutes later by a customer, who immediately called 911. On arrival, para…
-
psnet.ahrq.gov/node/49471/psn-pdf
December 01, 2004 - Carpe Diem (Seize the Day)
December 1, 2004
Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/carpe-diem-seize-day
The Case
A 53-year-old man presented for a new patient visit at a local medical clinic. He had several chronic
medical conditions including hypertension, h…
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-200-tech-specs.pdf
December 14, 2011 - Technical Specifications and Chart Abstraction Tool
Age upon
Age upon admission
Patient ID Race Ethnicity Gender Payer
Preferred
Language
admission (YEARS)
[e.g. for 12.5 year
(MONTHS) [
e.g. for 12.5
old, years = 12) year old,
months = 6]
1 White Non-Hispanic Female Medicaid English 12 3
2 Black Non-his…
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/engaging-senior-leaders.pdf
April 01, 2022 - Making It Work Tip Sheet: Engaging Senior Leaders in Preventing Healthcare-Associated Infections
AHRQ Safety Program for Intensive Care Units:
Preventing CLABSI and CAUTI
Making It Work Tip Sheet
Engaging Senior Leaders in Preventing Healthcare Associated Infections
This “Making It Work” tip sheet pro…