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psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - patients who have undergone the procedure must understand the risk of complications and learn how to recognize
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cds.ahrq.gov/sites/default/files/cds/artifact/1066/2023_Intervention_Content_T2DM_Part_Two_Counseling.xlsx
January 01, 2023 - Example Intervention Text
Example Patient-Facing Intervention Text: Prediabetes and Type 2 Diabetes: Part 2, Counseling
General Information
The example intervention text shown below is embedded in the Clinical Quality Language (CQL) files for the Prediabetes and Type 2 Diabetes: Part 2, Counseling artifact.
Implem…
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psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
August 20, 2018 - Failed Interpretation of Screening Tool: Delayed Treatment
Citation Text:
Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citatio…
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psnet.ahrq.gov/node/866992/psn-pdf
May 29, 2024 - Harm Reduction Strategies to Improve Safety for People
Who Use Substances
October 30, 2024
Salisbury-Afshar E, Gale B, Mossburg S. Harm Reduction Strategies to Improve Safety for People Who
Use Substances . PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-w…
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hcup-us.ahrq.gov/datainnovations/clinicalcontentenhancementtoolkit/hi24.pdf
September 01, 2013 - eHHIC: Hospital Engagement
1 | P a g e
Hawaii Health Information Corporation
Enhancing Hawaii Hospital Information Content (eHHIC)
Deliverable 1:
Hospital Engagement
2 | P a g e
TABLE OF CONTENTS
I. OBJECTIVE……………………………….………………..…………………………………………3
a. HOSPITAL RECRUITMENT…
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psnet.ahrq.gov/node/49519/psn-pdf
September 01, 2006 - Triple Handoff
September 1, 2006
Vidyarthi A. Triple Handoff. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/triple-handoff
Case Objectives
Appreciate the prevalence of handoffs and sign out related errors.
Understand the key elements of a safe and effective written and verbal sign out.
List Kotter’s 8 st…
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - Missed CANDOR Implementation Opportunities.
November 16, 2022
Schweitzer L. Missed CANDOR Implementation Opportunities. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
The Case
A 58-year-old man with a history of type 2 diabetes mellitus, hypertension, morbid obesit…
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Unexplained Apnea Under Anesthesia
February 1, 2003
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
Case Objectives
Clinical Objectives
List the causes of prolonged apnea in the operating room
Describe the steps in management …
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-removal.pptx
April 01, 2022 - Prompting Removal of Unnecessary Indwelling Urinary Catheters
Indwelling Urinary Catheter Removal
Maintaining Catheter Awareness and Prompting Removal
AHRQ Pub. No. 17-0019-5-EF
March 2018
AHRQ Safety Program for Intensive Care Units:
Preventing CLABSI and CAUTI
AHRQ Pub. No. 17(22)-0019
April 2022
AHRQ Safety Prog…
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psnet.ahrq.gov/node/49846/psn-pdf
November 01, 2018 - Supervision and Entrustment in Clinical Training:
Protecting Patients, Protecting Trainees
November 1, 2018
Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees.
PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-pr…
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/obtain-training-and-support/pharmacotherapy-training
January 01, 2023 - 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…
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psnet.ahrq.gov/node/45214/psn-pdf
July 13, 2016 - Recognizing quality improvement and patient safety
activities in academic promotion in departments of
medicine: innovative language in promotion criteria.
July 13, 2016
Staiger TO, Mills LM, Wong BM, et al. Recognizing Quality Improvement and Patient Safety Activities in
Academic Promotion in Departments of Medici…
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psnet.ahrq.gov/node/42769/psn-pdf
November 27, 2013 - Sepsis: recognizing the next event.
November 27, 2013
Kilburn FL, Bailey P, Price D. Sepsis: recognizing the next event. Nursing (Brux). 2013;43(10):14-6.
doi:10.1097/01.NURSE.0000434320.25397.53.
https://psnet.ahrq.gov/issue/sepsis-recognizing-next-event
This commentary describes the development and implementatio…
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psnet.ahrq.gov/node/37746/psn-pdf
May 14, 2008 - Reducing preventable medication safety events by
recognizing renal risk.
May 14, 2008
Fields W, Tedeschi C, Foltz J, et al. Reducing preventable medication safety events by recognizing renal
risk. Clin Nurse Spec. 2008;22(2):73-8; quiz 79-80. doi:10.1097/01.NUR.0000311795.69476.2f.
https://psnet.ahrq.gov/issue/red…
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psnet.ahrq.gov/node/42981/psn-pdf
March 19, 2014 - Recognizing and managing errors of cognitive
underspecification.
March 19, 2014
Duthie EA. Recognizing and managing errors of cognitive underspecification. J Patient Saf. 2014;10(1):1-5.
doi:10.1097/PTS.0b013e3182a5f6e1.
https://psnet.ahrq.gov/issue/recognizing-and-managing-errors-cognitive-underspecification
Inc…
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psnet.ahrq.gov/node/41595/psn-pdf
May 28, 2019 - Luer Connector Misconnections: Under-Recognized but
Potentially Dangerous Events.
May 28, 2019
Medical Product Safety Network. Silver Spring, MD; US Food and Drug Administration. November 19,
2008.
https://psnet.ahrq.gov/issue/luer-connector-misconnections-under-recognized-potentially-dangerous-events
This Web si…
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psnet.ahrq.gov/node/73617/psn-pdf
August 26, 2021 - Recognizing Unsafe Care: What It Is and How to Report It.
August 18, 2021
Patient Safety Foundation. August 26, 2021.
https://psnet.ahrq.gov/issue/recognizing-unsafe-care-what-it-and-how-report-it
This webinar introduced medical error and harm as related concepts to identify unsafe care and enhance
response, engag…
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psnet.ahrq.gov/node/837813/psn-pdf
January 21, 2021 - Recognizing Excellence in Diagnosis.
January 21, 2021
The Leapfrog Group.
https://psnet.ahrq.gov/issue/recognizing-excellence-diagnosis
Examination of diagnostic failure and identification of reduction strategies require multidisciplinary expertise
to be successful. This collaborative initiative will initially dev…
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psnet.ahrq.gov/node/45021/psn-pdf
April 06, 2016 - Scandal as a sentinel event—recognizing hidden
cost–quality trade-offs.
April 6, 2016
Bloche G. Scandal as a Sentinel Event--Recognizing Hidden Cost-Quality Trade-offs. N Engl J Med.
2016;374(11):1001-3. doi:10.1056/NEJMp1502629.
https://psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-t…
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psnet.ahrq.gov/node/43900/psn-pdf
February 11, 2015 - Once easily recognized, signs of measles now elude
young doctors.
February 11, 2015
Brown E, Lin RG II R, Xia R. Los Angeles Times. January 26, 2015.
https://psnet.ahrq.gov/issue/once-easily-recognized-signs-measles-now-elude-young-doctors
In light of the recent outbreak of measles in California, this newspaper ar…