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psnet.ahrq.gov/node/33678/psn-pdf
January 01, 2009 - In Conversation with…Thomas H. Gallagher, MD
January 1, 2009
In Conversation with…Thomas H. Gallagher, MD. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withthomas-h-gallagher-md
Editor's note: Thomas H. Gallagher, MD, is Associate Professor in the Department of Medicine and the
Departme…
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psnet.ahrq.gov/node/49639/psn-pdf
November 01, 2011 - Near Miss with Bedside Medications
November 1, 2011
Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications
Case Objectives
Understanding the definition of near miss—also known as close call.
Appreciate the importance of close calls in reducin…
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psnet.ahrq.gov/node/33729/psn-pdf
May 01, 2012 - The Emergence of the Trigger Tool as the Premier
Measurement Strategy for Patient Safety
May 1, 2012
Sharek PJ. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety.
PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-pa…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
June 02, 2025 - SAY:
The “Understand the Science of Safety” module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit discusses the importance of understanding system design, safe design principles, and valuing diverse input from team members. By analyzing patient safety as a science, frontline providers will provide a h…
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www.ahrq.gov/sites/default/files/2024-04/wolfson-report.pdf
January 01, 2024 - Final Progress Report: Conference: Physician-Level Interventions: What Works to Improve Quality of Care
Conference:
Physician-Level Interventions:
What Works to Improve Quality of Care
Principal Investigator: Daniel Wolfson
Team Members: Christine Cassel, Ann Greiner, Eric Holmboe
Organization: American Board of…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/find3.html
December 01, 2012 - Assessing the Health and Welfare of the HCBS Population
Availability and Use of State Medicaid HCBS
Previous Page Next Page
Table of Contents
Assessing the Health and Welfare of the HCBS Population
Introduction
HCBS Population
Availability and Use of State Medicaid HCBS
Outcome Indicators fo…
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psnet.ahrq.gov/node/49602/psn-pdf
April 01, 2010 - Anticoagulation: Held Too Long
April 1, 2010
Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
The Case
A 68-year-old woman with a history of mitral valve replacement with a mechanical valve was admitted with
abdominal pain. Because of the…
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psnet.ahrq.gov/node/854848/psn-pdf
October 31, 2023 - Delay in Malignancy Diagnosis Reflects Systemic Failures
October 31, 2023
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
The Case
A 32-year-old man presented to the hospital with…
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psnet.ahrq.gov/web-mm/ounce-prevention
February 17, 2011 - SPOTLIGHT CASE
An Ounce of Prevention
Citation Text:
Kucher N. An Ounce of Prevention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7…
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psnet.ahrq.gov/node/49408/psn-pdf
July 01, 2003 - Check the Wristband
July 1, 2003
Rosenthal M. Check the Wristband. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/check-wristband
The Case
The patient was a 28-year-old female awaiting ambulatory surgery. She was very anxious about the
impending surgery. The patient spoke English and appeared to be of aver…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
May 01, 2017 - Sensemaking and Learn from Defects for Perinatal Safety
AHRQ Safety Program for Perinatal Care
Sensemaking and Learn From Defects for Perinatal Safety
AHRQ Publication No. 17-0003-5-EF
May 2017
SAY:
The Sensemaking and Learn From Defects
module of the Safety Program for Perinatal
Care will help you identify…
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psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered
Nurses and Paramedics To Provide Home Visits to
Recently Discharged Patients at Highest Risk for Hospital
Readmission
April 7, 2022
https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-
paramedics-provide-home
Sum…
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - In Conversation with...James L. Reinertsen, MD
August 1, 2007
In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
Editor's Note: James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting
firm …
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psnet.ahrq.gov/node/49798/psn-pdf
July 01, 2017 - Pseudo-obstruction But a Real Perforation
July 1, 2017
Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
Case Objectives
Recognize acute colonic pseudo-obstruction and implement a medical management plan.
Ide…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/rapid-response/tool-rapid-response-systems.html
July 01, 2023 - Rapid Response for Perinatal Safety: Rapid Response Systems
AHRQ Safety Program for Perinatal Care
Purpose of the tool: This tool describes the key perinatal safety elements that support rapid response systems. The key safety elements are presented within the framework of the Comprehensive Unit-b…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation.pptx
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Facilitation Instructions for Conducting In Situ Simulations
AHRQ Safety Program for Perinatal Care
Establishing a Program of
In Situ Simulations
AHRQ Publication No. 17-0003-22-EF
May 2017
1
Learning Objectives
2
AHRQ Safety Program for Perinatal Care
In Situ Simulation…
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psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - The Forgotten Line
Citation Text:
Render ML. The Forgotten Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
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psnet.ahrq.gov/node/33696/psn-pdf
June 01, 2010 - In Conversation with…Pat Croskerry, MD, PhD
June 1, 2010
In Conversation with…Pat Croskerry, MD, PhD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
Editor's note: Pat Croskerry, MD, PhD, is a professor in emergency medicine at Dalhousie University in
Halifax, Nova…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/program-part2-facilitator-guide.pdf
November 01, 2019 - Antibiotic Stewardship Program Development: Part 2
AHRQ Safety Program for Improving
Antibiotic Use
1
AHRQ Pub. No. 17(20)-0028-EF
November 2019
Antibiotic Stewardship Program
Development: Part 2
Acute Care
Slide Title and Commentary Slide Number and Slide
Title Slide
Antibiotic …
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm3a.html
October 01, 2014 - Designing and Implementing Medicaid Disease and Care Management Programs
Section 3: Selecting and Targeting Populations for a Care Management Program (continued)
Previous Page Next Page
Table of Contents
Designing and Implementing Medicaid Disease and Care Management Programs
Introduction
Sectio…