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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49630/psn-pdf
    July 01, 2011 - Watch the Warfarin! July 1, 2011 Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/watch-warfarin Case Objectives Understand best practices for safe discharge of patients on warfarin. Describe recent advances in anticoagulation monitoring for ambulatory patients. Discu…

  2. A Summary of the First Annual Workshop of AHRQ’s Comparative Health System Performance Initiative | Agency for Healthcare Research and Quality

    www.ahrq.gov/chsp/events/coe-workshopissuebrief.html
    January 01, 2017 - A Summary of the First Annual Workshop of AHRQ’s Comparative Health System Performance Initiative Issue Brief The Agency for Healthcare Research and Quality and the Coordinating Center of the Comparative Health System Performance Initiative held a workshop September 29, 2016, to share learning a…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49869/psn-pdf
    July 02, 2019 - Failure to Rescue the Mother July 2, 2019 Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/failure-rescue-mother The Case A 27-year-old woman, G5 P2 A2, was first admitted to the hospital at 25 weeks of pregnancy for vaginal bleeding. An …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33645/psn-pdf
    February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? February 1, 2007 Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common Perspectiv…

  5. A Summary of the First Annual Workshop of AHRQ’s Comparative Health System Performance Initiative (pdf file)

    www.ahrq.gov/sites/default/files/publications/files/coe-workshopissuebrief.pdf
    January 11, 2017 - A Summary of the First Annual Workshop of AHRQ’s Comparative Health System Performance Initiative A Summary of the First Annual Workshop of AHRQ’s Comparative Health System Performance Initiative Based on the workshop discussions, a number of important takeaways will inform future work of the initiative: •…

  6. Final Progress Report: Dissemination of the PPRNet Model for Improving Medication Safety (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/wessell-report.pdf
    January 01, 2024 - Final Progress Report: Dissemination of the PPRNet Model for Improving Medication Safety 1. TITLE PAGE Final Progress Report Dissemination of the PPRNet Model for Improving Medication Safety Principal Investigator: Andrea M. Wessell, PharmD Team Members: Steven M. Ornstein, MD Ruth G. Jenkins, PhD Lynne S. Neme…

  7. CYP450 Drugs: Expect the Unexpected | PSNet

    psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
    October 19, 2022 - CYP450 Drugs: Expect the Unexpected Citation Text: Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49627/psn-pdf
    June 01, 2011 - The ECG Is Not Normal June 1, 2011 Zuger A. The ECG Is Not Normal. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/ecg-not-normal Case Objectives State how frequently physicians care for family or relatives. Describe the risks associated with caring for family members or relatives. Appreciate some of the s…

  9. Puh-Assessment (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.docx
    June 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing On-Time Pressure Ulcer Assessment The On-Time Pressure Ulcer Assessment incorporates elements from the Bates-Jensen Wound Assessment Tool (BWAT) with additional standardized treatment and intervention descriptors. The On-Time Pressure Ulcer Assess…

  10. Infectious Complications Related to the Catheter Other Than CAUTI | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cauti-tools/archived-webinars/infectious-complications-slides.html
    December 01, 2017 - Infectious Complications Related to the Catheter Other Than CAUTI Slide Presentation Slide 1 Infectious Complications Related to the Catheter Other than CAUTI Mohamad Fakih, MD, MPH Medical Director, Infection Prevention and Control St. John Hospital and Medical Center Professor of Medicine Wayne St…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865984/psn-pdf
    May 29, 2024 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. May 29, 2024 Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D- dimer. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-d…

  12. Diffusion of Responsibility Leads to Danger | PSNet

    psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
    November 08, 2013 - Diffusion of Responsibility Leads to Danger Citation Text: Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33788/psn-pdf
    June 01, 2015 - In Conversation With… Christine Cassel, MD June 1, 2015 In Conversation With… Christine Cassel, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-christine-cassel-md Editor's note: Christine Cassel, MD, is President and CEO of the National Quality Forum (NQF). Dr. Cassel, one of the foun…

  14. Around the Block | PSNet

    psnet.ahrq.gov/web-mm/around-block
    March 04, 2020 - Around the Block Citation Text: Minichiello T. Around the Block. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  15. Hospital Survey on Patient Safety Culture: Background and Information for Translators (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/infotranshsops.pdf
    September 01, 2009 - Hospital Survey on Patient Safety Culture: Background and Information for Translators Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture Background and Information for Translators September 2009 Purpose and Use of This Document In this document, w…

  16. Bowel Injury After Laparoscopic Surgery | PSNet

    psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery
    January 19, 2016 - Bowel Injury After Laparoscopic Surgery Citation Text: Moorthy K. Bowel Injury After Laparoscopic Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML …

  17. Stewardship-Facilitator-Guide (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/stewardship-facilitator-guide.docx
    June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use 1 Sustaining Your Antibiotic Stewardship Program Long-Term Care Slide Title and Commentary Slide Number and Slide Sustaining Your Antibiotic Stewardship Program Long-Term Care SAY: Welcome to this presentation, titled “Sustaining Your Antibiotic Stewardship Prog…

  18. Antibiotic Stewardship Program Development: Part 1 (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/program-part1-facilitator-guide.pdf
    November 01, 2019 - Antibiotic Stewardship Program Development: Part 1 AHRQ Safety Program for Improving Antibiotic Use 1 AHRQ Pub. No. 17(20)-0028-EF November 2019 Antibiotic Stewardship Program Development: Part 1 Acute Care Slide Title and Commentary Slide Number and Slide Antibiotic Stewardship Pr…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49787/psn-pdf
    March 01, 2017 - Diagnosing a Missed Diagnosis March 1, 2017 Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis The Case A 57-year old woman was admitted to the hospital with cough, slurred speech, confusion, and disorientation. She was taking mod…

  20. Central Venous Catheter Maintenance Facilitator Notes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-maintenance-notes.docx
    April 01, 2022 - Central Venous Catheter Maintenance Facilitator Notes CLABSI Module: Central Venous Catheter Maintenance Facilitator Guide Slide Number and Image This module, titled Central Venous Catheter Maintenance, is part of the Agency for Healthcare Research and Quality’s Safety Program for Intensive Care Units (ICUs) a…
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