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  1. Tacit Handover, Overt Mishap | PSNet

    psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
    August 01, 2006 - Tacit Handover, Overt Mishap Citation Text: Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846563/psn-pdf
    March 21, 2023 - Impact of System Failures on Healthcare Workers March 21, 2023 Zangaro G, Van CM, Mossburg S. Impact of System Failures on Healthcare Workers . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers Introduction The March 2022 conviction of RaDonda Vaught, a former nu…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49779/psn-pdf
    January 01, 2017 - The Empty Bag December 1, 2016 Vincent C. The Empty Bag. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/empty-bag The Case A 90-year-old woman with end-stage dementia was admitted to an acute care hospital for treatment of a hip fracture after a fall at a nursing home. During the hospitalization, her kidne…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49732/psn-pdf
    May 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…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846768/psn-pdf
    March 29, 2023 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. March 29, 2023 Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery The Ca…

  6. Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
    January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx Spotlight Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the ful…

  7. Spotlight (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
    January 01, 2019 - Spotlight Spotlight Mistaken Attribution, Diagnostic Misstep * Source and Credits This presentation is based on the January 2019 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49450/psn-pdf
    June 01, 2004 - The Wrong Shot: Error Disclosure June 1, 2004 Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure Case Objectives Describe the rationale for disclosing harmful errors to patients. Describe the specific information that patie…

  9. Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
    January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx Spotlight Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the full …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49558/psn-pdf
    April 01, 2008 - Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad April 1, 2008 Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad Case Objectives Understand the indications for antibiotic treatment in …

  11. Breakage of a PICC Line | PSNet

    psnet.ahrq.gov/web-mm/breakage-picc-line
    June 21, 2023 - SPOTLIGHT CASE Breakage of a PICC Line Citation Text: Dimov V. Breakage of a PICC Line. 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 …

  12. SOPS® Nursing Home Survey Items and Composite Measures (Spanish) (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-survey-items-composite-spanish.pdf
    September 01, 2024 - SOPS® Nursing Home Survey Items and Composite Measures (Spanish) SOPS® Nursing Home Survey Items and Composite Measures Version: 1.0 Language: Spanish Notes • For more information on getting started, selecting a sample, determining data collection methods, establishing data collection procedures, conduct…

  13. Premature Extubation | PSNet

    psnet.ahrq.gov/web-mm/premature-extubation
    May 25, 2011 - Premature Extubation Citation Text: Sagana R, Hyzy RC. Premature Extubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…

  14. Prompting Removal of Unnecessary Indwelling Urinary Catheters Facilitator Notes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-removal-notes.docx
    April 01, 2022 - Prompting Removal of Unnecessary Indwelling Urinary Catheters Facilitator Notes CAUTI Module: Indwelling Urinary Catheter Removal Facilitator Guide Slide Number and Image This module, titled “Indwelling Urinary Catheter Removal,” is part of the Agency for Healthcare Research and Quality’s Safety Program for In…

  15. Evidence Behind Pain, Agitation, and Delirium: Assessments and Sedation Management: Slide Presentation | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/mvp/modules/technical/pain-mgmt-slides.html
    January 01, 2017 - Evidence Behind Pain, Agitation, and Delirium: Assessments and Sedation Management: Slide Presentation AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients Evidence Behind Pain, Agitation, and Delirium: Assessments and Sedation Manageme…

  16. Indwelling Urinary Catheter Indications Facilitator Notes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-indications-notes.docx
    April 01, 2022 - Indwelling Urinary Catheter Indications Facilitator Notes CAUTI Module: Indwelling Urinary Catheter Indications Facilitator Guide Slide Number and Image This module, titled “Indwelling Urinary Catheter Indications” is part of the Agency for Healthcare Research and Quality’s Safety Program for Intensive Care Uni…

  17. Findings | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/findings.html
    August 01, 2022 - Planning Grants Final Evaluation Report Findings Previous Page Next Page Table of Contents Planning Grants Final Evaluation Report Executive Summary Introduction Methodology Findings Appendix A. Grantee Profiles Appendix B. References Improving Communication Four planni…

  18. 040-Mrsa-Surveillance-Notes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/040-mrsa-surveillance-notes.docx
    October 01, 2024 - AHRQ Safety Program for MRSA Prevention MRSA Surveillance ICU & Non-ICU Slide Title and Commentary Slide Number and Slide MRSA Surveillance SAY: Welcome to this presentation on MRSA Surveillance, which will explain how various approaches to MRSA surveillance help to prevent transmission of MRSA in intensive care u…

  19. Module 1: Overview | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/mod1.html
    February 01, 2023 - Preventing CAUTI in the ICU Setting: Facilitator’s Guide Module 1: Overview Previous Page Next Page Table of Contents Preventing CAUTI in the ICU Setting: Facilitator’s Guide Introduction Module 1: Overview Module 2: Urinary Catheter Maintenance Module 3: Conversations Around Device Necessit…

  20. Section 6: Operating a Care Management Program | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm6.html
    October 01, 2014 - Designing and Implementing Medicaid Disease and Care Management Programs Section 6: Operating a Care Management Program Previous Page Next Page Table of Contents Designing and Implementing Medicaid Disease and Care Management Programs Introduction Section 1: Planning a Care Management Program …
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