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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosureMay 01, 2011 - SPOTLIGHT CASE The Wrong Shot: Error Disclosure Citation Text: Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Sch…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49829/psn-pdfMay 01, 2018 - Root Cause Analysis Gone Wrong May 1, 2018 Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney transplant. A suitabl… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/857259/psn-pdfNovember 30, 2023 - Medication Mix-Up Leads to Patient Death November 30, 2023 Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death The Case An 81-year-old man was transferred from an outside hospital and admitted to the intensive car… -
psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problemOctober 19, 2022 - SPOTLIGHT CASE Resuscitation Errors: A Shocking Problem Citation Text: Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: …
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33736/psn-pdfSeptember 01, 2012 - In Conversation With… Jack Needleman, PhD September 1, 2012 In Conversation With… Jack Needleman, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-jack-needleman-phd Editor's note: Jack Needleman, PhD, is a Professor in the Department of Health Policy and Management at UCLA School of P… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/855057/psn-pdfOctober 31, 2023 - Addressing Workplace Violence and Creating a Safer Workplace October 31, 2023 Jones CB, Sousane Z, Mossburg S. Addressing Workplace Violence and Creating a Safer Workplace. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace While violence in the w… -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdfMarch 12, 2008 - Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes Karla Miller, PharmD; Manisha Shah, MBA, RT; Lau…
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psnet.ahrq.gov/web-mm/standard-deviationsJanuary 01, 2006 - SPOTLIGHT CASE Standard Deviations Citation Text: Sabin JE. Standard Deviations. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73456/psn-pdfJune 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia June 30, 2021 Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49639/psn-pdfNovember 01, 2011 - Near Miss with Bedside Medications November 1, 2011 Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications Case Objectives Understanding the definition of near miss—also known as close call. Appreciate the importance of close calls in reducin… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49705/psn-pdfJanuary 01, 2020 - A "Reflexive" Diagnosis in Primary Care April 1, 2014 Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care Case Objectives Appreciate that primary care doctors may be caring for an increasing number of patients wi… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49516/psn-pdfAugust 01, 2006 - Physical Diagnosis: A Lost Art? August 1, 2006 Thompson GR, Verghese A. Physical Diagnosis: A Lost Art? PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art Case Objectives Appreciate the decline in proficiency and reliance on physical examination skills among health care providers. … -
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/098-cusp-why-choose-cusp-approach.pptxOctober 01, 2024 - AHRQ Safety Program for MRSA Prevention AHRQ Safety Program for MRSA Prevention Why Choose a CUSP Approach? ICU & Non-ICU AHRQ Pub. No. 25-0007 October 2024 AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU Why Choose a CUSP Approach? 1 Educational Obje…
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www.ahrq.gov/patient-safety/settings/hospital/match/chapter-3.htmlJuly 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation Chapter 3. Developing Change: Designing the Medication Reconciliation Process Previous Page Next Page Table of Contents Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Recon…
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Puh-Assessment (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.pdfJune 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 Ulc… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49732/psn-pdfMay 01, 2015 - Errors in Sepsis Management May 1, 2015 Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/errors-sepsis-management Case Objectives Define sepsis, severe sepsis, and septic shock. Describe the severe sepsis/septic shock resuscitation bundle. Recognize commonly encou… -
www.ahrq.gov/hai/tools/mvp/modules/cusp/overview-cusp-mvp-facguide.htmlFebruary 01, 2017 - Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients: Facilitator Guide AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients Say: …
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www.ahrq.gov/es/patient-safety/settings/hospital/match/chapter-3.htmlJuly 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation Chapter 3. Developing Change: Designing the Medication Reconciliation Process Previous Page Next Page Table of Contents Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Recon…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/forming-cuspteam-facguide.docxJanuary 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle Slide Title and Commentary Slide Number and Slide Title Slide Forming a Comprehensive Unit-based Safety Program Team SAY: Today, we will briefly revisit the key concepts of the Comprehensive Unit-based Safety Program or CUSP. Then, we will dive into a focused di…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49741/psn-pdfSeptember 01, 2015 - Abdominal Pain in Early Pregnancy September 1, 2015 Kilpatrick CC. Abdominal Pain in Early Pregnancy. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy Case Objectives Recognize when nausea and vomiting in pregnancy is abnormal. Identify the most common causes of non-obstetric a…
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