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psnet.ahrq.gov/node/49678/psn-pdf
March 01, 2013 - A Weighty Mistake
March 1, 2013
Bokser SJ. A Weighty Mistake. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/weighty-mistake
Case Objectives
Understand factors associated with weight-based dosing medication errors in pediatric populations.
Describe how adoption of computerized provider order entry (CPOE) s…
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psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overdose-pediatric-patient
October 04, 2023 - From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient
Citation Text:
Markham K, Usui M, Smith C. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of…
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digital.ahrq.gov/program-overview/research-reports/2021-year-review/research-overview
January 01, 2021 - Research Overview
Digital healthcare knowledge and tools can enhance the efforts of patients, clinicians, and health systems working to improve healthcare quality and safety. AHRQ’s DHR program funds research to create actionable findings on what and how digital healthcare works best for t…
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hcup-us.ahrq.gov/datainnovations/grants.jsp
July 01, 2016 - Enhanced State Data Grants
An official website of the Department of Health & Human Services
Search All AHRQ Websites
Careers
Contact Us
Espanol
FAQs
Email Updates
…
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psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
August 20, 2018 - Buprenorphine and the Medically Ill Patient
Citation Text:
McCance-Katz EF. Buprenorphine and the Medically Ill Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX E…
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psnet.ahrq.gov/node/49760/psn-pdf
May 01, 2016 - Mismanagement of Delirium
May 1, 2016
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/mismanagement-delirium
The Case
An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although
fitted with a cast at a regional ho…
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psnet.ahrq.gov/node/33643/psn-pdf
December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA
December 1, 2006
In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
Editor's Note: J. Bryan Sexton, PhD, MA, is Assistant Professor, Department of Anesthesiology and
Critic…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/001-ss-antimicrobial-prophylaxis-1-fg.docx
April 01, 2025 - AHRQ Safety Program for MRSA
Prevention: Targeting SSI
Antimicrobial Prophylaxis: Part 1
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
Slide Title and Commentary
Slide Number and Slide
Antimicrobial Prophylaxis: Part 1
SAY:
Hello. Welcome to this presentation on antim…
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psnet.ahrq.gov/print/pdf/node/866984
January 01, 2020 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Interdisciplinary teamwork
Curated Library
Foundations
Medical teamwork and the evolution of safety science: a critical review.
Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22:13-27.
In this narrative review, the authors contr…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Deis_82.pdf
June 03, 2008 - Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement
Transforming the Morbidity and Mortality Conference
into an Instrument for Systemwide Improvement
Jamie N. Deis, MD; Keegan M. Smith, MD; Michael D. Warren, MD;
Patricia G. Throop, BSN, CPHQ; Gerald B. Hickson, MD; …
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www.ahrq.gov/evidencenow/projects/state/how-to-guide/guide3.html
August 01, 2024 - Research Network, the Deep South Continuing Medical Education Network, and the Rural Research Alliance of Community … Pharmacies) to reach clinicians serving high-risk and underserved communities.
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/medical-evidence-communication_research-protocol.pdf
July 31, 2012 - Academic health care institutions
• Churches, fraternal organizations, professional or social clubs, pharmacies … Community-based settings such as
churches, fraternal organizations,
professional or social clubs,
pharmacies … community-based settings such as churches, fraternal organizations,
professional or social clubs, pharmacies
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - SPOTLIGHT CASE
Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.
Citation Text:
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/otimefallspx-implmatls.pdf
June 02, 2025 - Falls Prevention Self-Assessment Worksheet - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention
Agency for Healthcare Research and Quality Safety Program for Nursing Homes: On-Time Falls Prevention
AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention
Falls Prevention Self-Assessment Wo…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_7.pdf
October 01, 2016 - New Models of Primary Care Workforce and Financing - Case Example #7: Cherokee Health Systems
New Models of Primary Care
Workforce and Financing
Case
Example Cherokee Health Systems
7
New Models of Primary Care Workforce
and Financing
Case Example #7: Cherokee Health Systems
…
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digital.ahrq.gov/sites/default/files/docs/citation/k08hs24764-nanji-final-report-2022.pdf
January 01, 2022 - Preventing Perioperative Medication Errors and Adverse Drug Events Through the Use of Clinical Decision Support - Final Report
Preventing Perioperati…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/congestive-heart-failure-medicines_research.pdf
March 01, 2010 - MEDICAL MANAGEMENT OF CONGESTIVE HEART FAILURE AND THE EFFECTIVENESS OF ISOSORBIDE DINITRATE AND HYDRALAZINE
The DEcIDE (Developing Evidence to Inform Decisions about Effectiveness) network is part of
AHRQ’s Effective Health Care Program. It is a collaborative network of research centers that
support the rapi…
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effectivehealthcare.ahrq.gov/sites/default/files/ch_5-user-guide-to-ocer_130129.pdf
January 01, 2012 - 59
Abstract
This chapter discusses considerations for comparator selection in observational comparative effectiveness
research (CER). Comparison groups should reflect clinically meaningful choices in real world practice
and be chosen based on the study question being addressed. Recognizing the implications and pote…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_5.pdf
October 01, 2016 - New Models of Primary Care Workforce - Case Example #5: WellMed
New Models of Primary Care
Workforce and Financing
Case
Example WellMed
5
New Models of Primary Care Workforce
and Financing
Case Example #5: WellMed
Prepared for:
Agency for Healthcare Research and Qu…
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www.ahrq.gov/sites/default/files/2025-03/joo-report.pdf
January 01, 2025 - Final Progress Report: Reducing Diagnostic Error to Improve Patient Safety in COPD and Asthma (REDEFINE Study)
1. Reducing Diagnostic Error to Improve Patient Safety in COPD and Asthma
(REDEFINE Study)
Principal Investigator and Team Members/Organization:
Min J. Joo, MD, MPH, Department of Medicine, College of Medi…