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4001. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49868/psn-pdf
      July 02, 2019 - Delayed Clozapine Prescription in an Elderly Man With Dementia July 2, 2019 Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia The Case An 86-year-old man with neurode…

4002. Evaluation of Measures in the Scan | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/rep2.html
      June 01, 2010 - Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services Evaluation of Measures in the Scan Previous Page Next Page Table of Contents Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services Executive Summary Introduction and Scan Met…

4003. Client Functioning Measures and Gaps | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/rep3.html
      June 01, 2010 - Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services Client Functioning Measures and Gaps Previous Page Next Page Table of Contents Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services Executive Summary Introduction and Scan M…

4004. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866621/psn-pdf
      August 28, 2024 - Application of Safety-II Principles August 28, 2024 Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/application-safety-ii-principles Traditional approaches to patient safety have often been reactive rather than proactive, seeki…

4005. Info FAQs | Agency for Healthcare Research and Quality
      www.ahrq.gov/faqs/index.html?page=4
      June 12, 2025 - Frequently Asked Questions Check to find the answers to your questions about the Agency for Healthcare Research and Quality (AHRQ) programs and activities. You can search by category or key words. You can also send us your questions or website feedback here. We will respond to your requests based on the bes…

4006. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49441/psn-pdf
      March 01, 2004 - Fumbled Handoff March 1, 2004 Vidyarthi A. Fumbled Handoff. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/fumbled-handoff The Case A 73-year-old female with history of hypertension, non-insulin dependent diabetes mellitus (NIDDM), and chronic renal insufficiency was admitted for an elective sigmoid resect…

4007. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33679/psn-pdf
      January 01, 2009 - Disclosure of Medical Error January 1, 2009 Kachalia A. Disclosure of Medical Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/disclosure-medical-error Perspective Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts advocate that greater discl…

4008. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49409/psn-pdf
      July 01, 2003 - Feeling No Pain July 1, 2003 Bogner MS. Feeling No Pain. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/feeling-no-pain The Case A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…

4009. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49404/psn-pdf
      June 01, 2003 - Not a Miscarriage June 1, 2003 Learman LA. Not a Miscarriage. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/not-miscarriage The Case A 32-year-old woman, gravida 3, para 1, with a history of Type 2 diabetes mellitus on metformin, presented at 7 and 2/7 weeks by last menstrual period (LMP). The patient rep…

4010. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49420/psn-pdf
      October 01, 2003 - To LP or Not LP October 1, 2003 Landrigan CP. To LP or Not LP. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/lp-or-not-lp The Case A 4-month-old male infant was seen in the office setting of a large multisite practice. He presented with fever and irritability without an obvious source. He was referred to …

4011. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60169/psn-pdf
      March 25, 2020 - Is that solution for IV or irrigation?: Fluid administration errors in the operating room. March 25, 2020 Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-erro…

4012. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49842/psn-pdf
      September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment September 1, 2018 Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment The Case As part of…

4013. The Challenges of Aggregating Patient Data from Multiple Sites (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/2006King_051611comp.pdf
      June 16, 2021 - The Challenges of Aggregating Patient Data from Multiple Sites Volunteer eHealth Initiative The Challenges of Aggregating Patient Data from Multiple Sites Janet King Technical Project Manager Regional Health Initiatives Vanderbilt Center for Better Health Funding: AHRQ Contract 290-04-0006; State of Tennessee;…

4014. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49435/psn-pdf
      February 01, 2004 - X-ray Flip February 1, 2004 Shapiro MJ. X-ray Flip. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/x-ray-flip The Case A 19-year-old man presented to the emergency department with respiratory distress after blunt chest trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…

4015. Spotlight on Georgia -- National Evaluation of the CHIPRA Quality Demonstration Grant Program (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-georgia-state-snapshot.pdf
      January 01, 2018 - Spotlight on Georgia -- National Evaluation of the CHIPRA Quality Demonstration Grant Program This brief highlights the major strategies, lessons learned, and outcomes from Georgia’s experience from February 2010 to February 2016 with the quality demonstration funded by the Centers for Medicare & Medicaid Service…

4016. Measure Descriptions for Daily Early Mobility: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/technical/daily-early-mobility-slides.html
      February 01, 2017 - Measure Descriptions for Daily Early Mobility: Slide Presentation AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients Measure Descriptions for Daily Early Mobility Slide 2: Learning Objectives After this session, you will be able…

4017. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module3/module-3-slides.pptx
      March 01, 2017 - PowerPoint Presentation Module 3: Staff Empowerment AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Long-Term Care Safety Modules AHRQ Pub. No. 16(17)-0003-03-EF March 2017 1 Objectives Cite staff empowerment concepts Discuss how staff empowerment contributes to a culture of resident safety, leading to improved…

4018. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/assess-resident-UTI-slides.pptx
      June 01, 2021 - PowerPoint Presentation Assessment of the Resident With a Suspected Urinary Tract Infection Long-Term Care AHRQ Safety Program for Improving Antibiotic Use AHRQ Pub. No. 17(21)-0029 June 2021 AHRQ Safety Program for Improving Antibiotic Use – Long-Term Care Assessment UTI 1 Objectives Explain the terms urinary tr…

4019. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
      February 01, 2012 - Spotlight Case July 2008 Spotlight Case E-prescribing: E for Error? 1 2 Source and Credits This presentation is based on the February 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Elisa W. Ashton, PharmD, Assistant Clinical Professor, Departm…

4020. Central Venous Catheter Indications and Alternatives
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-alternatives.pptx
      April 01, 2022 - Central Venous Catheter Indications and Alternatives Indwelling Urinary Catheter Alternatives Avoiding Placement and Determining Appropriateness AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI AHRQ Pub. No. 17(22)-0019 April 2022 1 Avoid Unnecessary Urinary Catheter Placement1,2 Patel…