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  1. psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
    June 28, 2023 - SPOTLIGHT CASE Prolonged DKA in Pregnancy: A Case of Communication Breakdown. Citation Text: Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services…
  2. digital.ahrq.gov/sites/default/files/docs/survey/improving-sickle-cell-transitions-focus-group-moderator-guide-%20it-developers.pdf
    June 16, 2021 - Improving Sickle Cell Transitions, Focus Group Moderator Guide: IT Developers Improving Sickle Cell Transitions, Focus Group Moderator Guide: IT Developers The Lewin Group, Inc., Falls Church Virginia This is a focus group guide designed to be conducted with developers across a health care system. The tool …
  3. www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Ruddick_61.pdf
    March 09, 2008 - Using Root Cause Analysis to Reduce Falls in Rural Health Care Facilities Using Root Cause Analysis to Reduce Falls in Rural Health Care Facilities Patricia Ruddick, RN, MSN; Karen Hannah, MBA; Charles P. Schade, MD; Gail Bellamy, PhD; John Brehm, MD; David Lomely, BA. Abstract Prevention of patient falls i…
  4. psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery 1 Source and Credits This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Andrew P.J. …
  5. psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
    June 01, 2015 - SPOTLIGHT CASE Empiric Steroids: the Good, the Bad, and the Ugly Citation Text: Harris ED. Empiric Steroids: the Good, the Bad, and the Ugly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format:…
  6. psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
    January 01, 2014 - SPOTLIGHT CASE Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad Citation Text: Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citatio…
  7. digital.ahrq.gov/sites/default/files/docs/2010-02-24%20Transitions%20In%20Care%20(4).pdf
    January 01, 2010 - A National Web Conference on Transitions in Care Managing Patient Care Transitions: How Health IT  Can Reduce Unnecessary Re‐Hospitalization February 24, 2010 Presenters:  Stephen Jencks Independent Consultant In Health Care Safety  Brian Jack Department of Family Medicine at Boston University School of  …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49546/psn-pdf
    October 17, 2007 - Do Not Disturb! October 1, 2007 Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/do-not-disturb Case Objectives Define professionalism. Discuss behaviors associated with lack of professionalism. Outline steps one should take if a significant breach of professionalism is …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74713/psn-pdf
    January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking January 26, 2022 Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking Disclosure of Relevant Financial Relationships: As a provider ac…
  10. www.ahrq.gov/diagnostic-safety/research/grants-2022.html
    August 01, 2025 - Diagnostic Safety Centers of Excellence Grants Awarded in FY 2022 In fiscal year 2022, Congress authorized funding to support AHRQ's research to address failures in the diagnostic process, which may include the establishment of Research Centers of Diagnostic Excellence to develop systems, measures, and new tech…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33583/psn-pdf
    March 01, 2023 - Simulation Training March 1, 2023 Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/simulation-training Originally published in 2014 by researchers at the University of California, San Francisco. Updated in March 2023, by Jennifer J. Edwards, MS, RN, CHSE…
  12. www.ahrq.gov/data/apcd/backgroundrpt/review.html
    July 01, 2022 - Inventory and Prioritization of Measures To Support the Growing Effort in Transparency Using All-Payer Claims Databases Reviewing the Landscape of All-Payer Claims Databases Previous Page Next Page Table of Contents Inventory and Prioritization of Measures To Support the Growing Effort in Transparen…
  13. integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/introduction-medication-assisted-treatment
    February 01, 2025 - An official website of the Department of Health & Human Services Search All AHRQ Sites Careers Contact Us Español FAQs Email Updates The Academy Integrating Behavioral Health & Primary Care Expand Navi…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851870/psn-pdf
    July 31, 2023 - In Conversation with... Regina Hoffman about Building Capacity for Patient Safety July 31, 2023 In Conversation with.. Regina Hoffman about Building Capacity for Patient Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety Editor’s no…
  15. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
    January 01, 2020 - Spotlight Spotlight Some Patients Can’t Wait: Improving Timeliness of Emergency Department Care Source and Credits • This presentation is based on the 2020 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm • Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD ○ Editor…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49454/psn-pdf
    July 01, 2004 - Novel Drug Misuse July 1, 2004 Angus DC, Milbrandt EB. Novel Drug Misuse. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/novel-drug-misuse Case Objectives Define the inclusion and exclusion criteria for patients in PROWESS. Understand why the FDA included APACHE score as an indication criterion for drotrec…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49618/psn-pdf
    February 01, 2011 - One Toxic Drug Is Not Like Another February 1, 2011 Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/one-toxic-drug-not-another Case Objectives Distinguish between the three distinct regulatory processes of board certification, medical licensure, and credential…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33770/psn-pdf
    August 01, 2014 - In Conversation With… Urmimala Sarkar, MD, MPH August 1, 2014 In Conversation With… Urmimala Sarkar, MD, MPH. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph Editor's note: Urmimala Sarkar, MD, MPH, is associate professor of medicine at the University of California, S…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73300/psn-pdf
    July 01, 2022 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care May 26, 2021 https://psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care Summary The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs,…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74252/psn-pdf
    January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO January 12, 2022 In Conversation With.. Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda…