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psnet.ahrq.gov/node/49456/psn-pdf
July 12, 2004 - Glucose Roller Coaster
July 1, 2004
Sharpe B. Glucose Roller Coaster. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/glucose-roller-coaster
The Case
A 71-year-old woman with congestive heart failure was admitted to the hospital. Her medical history was
significant for dialysis-dependent, end-stage kidney d…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/composite-measures-spanish.pdf
January 01, 2015 - Spanish Community Pharmacy Survey on Patient Safety Culture Items and Dimensions
Spanish Translation of AHRQ’s Ambulatory Surgery Center Survey on Patient Safety Culture
November 2014
This document explains the process that was used to develop a Spanish translation of the Agency for
Healthcare Research and Qualit…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/indwelling-urinary-catheter-use/catheter-care/slides.html
March 01, 2017 - Catheter Care and Maintenance
AHRQ Safety Program for Long-Term Care: CAUTI
Slide 1: Catheter Care and Maintenance
National Content Series
Slide 2: Objectives
Upon completion of this webinar participants will be able to—
Explain best practices of indwelling urinary catheter care;
Review the do…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/090-decolonization-implementation.pptx
April 01, 2025 - PowerPoint Presentation
Decolonization Implementation
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
AHRQ Pub. No. 25-0029
April 2025
AHRQ Safety Program for MRSA Prevention: Targeting SSI
AHRQ Safety Program for MRSA Prevention | Surgical Services
Decolonization Implemen…
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hcup-us.ahrq.gov/db/vars/ageday/kidnote.jsp
September 01, 2008 - Healthcare Cost and Utilization Project (HCUP) KID Notes
An official website of the Department of Health & Human Services
Search All AHRQ Websites
Careers
Contact Us
Espanol
FAQs…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/epc-making-sure-evidence-understood.pdf
July 01, 2020 - Making Sure That Evidence Is Understood and Used
Making Sure That Evidence
Is Understood and Used:
Engaging With the Agency
for Healthcare Research and
Quality in Evidence Reviews
Why Engage With AHRQ?
The Agency for Healthcare Research and Quality (AHRQ) wants to engage with
organizations to promote the use…
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www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-jul2023.pdf
November 03, 2023 - Federal Interagency Workgroup on Improving Diagnostic Safety: July Meeting Summary
Federal Interagency Workgroup:
Improving Diagnostic Safety and Quality in Healthcare
July Meeting Summary
Workgroup Goal: Established in response to Senate Report 115-150. The Senate Committee on
Appropriations requested that…
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www.ahrq.gov/sites/default/files/2024-02/yazdany-report.pdf
January 01, 2024 - measurable through an EHR, each patient receiving a class of
medication associated with any of these processes
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digital.ahrq.gov/principal-investigator/ebeling-toni
January 01, 2023 - Ebeling, Toni
EMR Planning to Improve North Iowa Health Care
Description
Designed a system-wide patient-centered planning process and an EHR implementation plan that securely exchanged patient information within and across diverse health care settings for the Hancock County Me…
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-overview/slide02.html
October 01, 2014 - 2. 2008 PHS Clinical Practice Guideline Update: Treating Tobacco Use and Dependence
Treating Tobacco Use and Dependence: 2008 Update Overview
Text version of slide presentation.
Brief history and developmental process.
Key findings of interest.
Getting more information.
Note: This and all follo…
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psnet.ahrq.gov/node/37419/psn-pdf
December 19, 2007 - Ensuring medication reconciliation.
December 19, 2007
Georgia K, Kinney K, Pace A, Helton K. Patient Saf Qual Healthc. November / December 2007.
https://psnet.ahrq.gov/issue/ensuring-medication-reconciliation
The authors describe the team-based process they used to improve medication management at the
admission, t…
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www.ahrq.gov/patient-safety/settings/hospital/candor/videos/disclosure.html
August 01, 2022 - Disclosure Conversation with Family: Video
AHRQ Communication and Optimal Resolution Toolkit
Communication and Optimal Resolution (CANDOR) is a process that health care institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm. This video d…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/videos/notification.html
August 01, 2022 - Notification of Adverse Event: Video
AHRQ Communication and Optimal Resolution Toolkit
Communication and Optimal Resolution (CANDOR) is a process that health care institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm. This video demonst…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/videos/conversation.html
August 01, 2022 - Conversation with Family: Video
AHRQ Communication and Optimal Resolution Toolkit
Communication and Optimal Resolution (CANDOR) is a process that health care institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm. This video demonstrates…
-
psnet.ahrq.gov/node/33959/psn-pdf
January 17, 2012 - Healthcare Failure Mode and Effect Analysis.
January 17, 2012
National Center for Patient Safety.
https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis
These materials provide an introduction to the purpose of healthcare failure mode and effect analysis
(HFMEA), the steps of the HFMEA process, a…
-
psnet.ahrq.gov/node/40591/psn-pdf
July 06, 2011 - Medical misdiagnoses can have fatal consequences.
July 6, 2011
Olsen D. State Journal-Register. June 26, 2011.
https://psnet.ahrq.gov/issue/medical-misdiagnoses-can-have-fatal-consequences
This newspaper article discusses a case of diagnostic error, explores the complexity of the diagnostic
process, and provides t…
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cdsic.ahrq.gov/sites/default/files/2024-09/Final%20IAS%20PC%20CDS%20Case%20Studies%20Report_2.pdf
January 01, 2024 - Below,
we describe the domains we used as our organizing framework for the case studies and our processes … interoperable PC CDS
resources, MyPAIN and PainManager, to expand upon the shared decision making
processes … PC CDS Integration
Evaluation of PC CDS integration with clinical care processes and patients’ lifeflows … Finally, organizational differences exist in the governance and review processes
required to implement … text messages that alert them to a higher risk for elevated
HbA1c but need clarification of the new processes
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hcup-us.ahrq.gov/datainnovations/clinicalcontentenhancementtoolkit/ny14.pdf
March 20, 2012 - Providers that believe these historical data are inaccurate because of changes in their
processes of
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-exercise-instructions.pdf
June 02, 2025 - • Debrief the group to answer questions, refine your processes, and discuss contingencies
for addressing
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psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - following resources and skills are needed to implement the HRTIC
program:
https://psnet.ahrq.gov//#2
Processes