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  1. psnet.ahrq.gov/web-mm/mismanagement-delirium
    February 13, 2014 - Mismanagement of Delirium Citation Text: Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
  2. digital.ahrq.gov/sites/default/files/docs/publication/BarrierstoMeaningfulUseAppendixF.pdf
    October 31, 2013 - Appendix F to the Final Report Barriers to Meaningful Use in Medicaid: Analysis and Recommendations Form Approved OMB No. 0935-0186 Exp. Date 10/31/2013 F-1 Appendix F Barriers to Meaningful Use of Electronic Health Records in Medicaid Focus Group Moderator’s Guide For “virtual” use with non-users of E…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851870/psn-pdf
    July 31, 2023 - In Conversation with... Regina Hoffman about Building Capacity for Patient Safety July 31, 2023 In Conversation with.. Regina Hoffman about Building Capacity for Patient Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety Editor’s no…
  4. psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
    March 24, 2025 - In Conversation with…Albert Wu, MD, MPH May 1, 2011  Citation Text: In Conversation with…Albert Wu, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837791/psn-pdf
    August 05, 2022 - Patient Safety in the Ambulatory Care Setting August 5, 2022 Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting Introduction There is no way to review the year 2021 in quality and …
  6. psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
    March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? Citation Text: Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. C…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74713/psn-pdf
    January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking January 26, 2022 Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking Disclosure of Relevant Financial Relationships: As a provider ac…
  8. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
    January 01, 2022 - Spotlight Spotlight Patient Safety Events Involving Opioid Dose Stacking Source and Credits • This presentation is based on the January 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…
  9. hcup-us.ahrq.gov/reports/factsandfigures/2007/sources_methods.jsp
    January 01, 2007 - HCUP Facts and Figures 2007: Statistics on Hospital-Based Care in the United States An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact …
  10. psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
    August 21, 2015 - SPOTLIGHT CASE Order Interrupted by Text: Multitasking Mishap Citation Text: Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49522/psn-pdf
    November 01, 2006 - Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality November 1, 2006 Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-…
  12. psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms
    April 19, 2023 - In Conversation With… Karl Bilimoria, MD, MS August 1, 2017  Citation Text: In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation …
  13. psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
    November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures Citation Text: Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49852/psn-pdf
    February 01, 2019 - Triaging Interhospital Transfers February 1, 2019 Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/triaging-interhospital-transfers Case Objectives Recognize that transfer of patients between acute care hospitals is common. Realize that the interhospital transfer…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49579/psn-pdf
    March 21, 2009 - All in the History March 21, 2009 Fee C. All in the History. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/all-history Case Objectives Describe the Emergency Medical Treatment and Active Labor Act (EMTALA) and understand that it does not apply to transfers to emergency departments from non-acute care faci…
  16. Psn-Pdf (pdf file)

    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…
  17. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/156-what-are-4es.pptx
    October 01, 2024 - AHRQ Safety Program for MRSA Prevention AHRQ Safety Program for MRSA Prevention What Are the 4 Es? ICU/Non-ICU AHRQ Pub. No. 25-0007 October 2024 AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU What Are The Four Es 1 Educational Objectives Define the 4 Es framework—Engage, Educate, Execute, Evaluate—and ex…
  18. psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-paramedics-provide-home
    October 30, 2024 - The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission Save Save to your library Print Download PDF Share Facebook Twitter Linkedin C…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60865/psn-pdf
    August 31, 2020 - In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA- BC-FACHE August 31, 2020 In Conversation With.. Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache Editor’s Note: Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837660/psn-pdf
    July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse Outcomes July 8, 2022 Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes The Cases Case 1: A 64-year-old man came in for a routine bron…