-
psnet.ahrq.gov/node/49507/psn-pdf
April 01, 2006 - Is the "Surgical Personality" a Threat to Patient Safety?
April 1, 2006
Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety? PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
Case Objectives
Describe the myth of the "surgical personality"
Identify featu…
-
psnet.ahrq.gov/node/49456/psn-pdf
July 12, 2004 - Glucose Roller Coaster
July 1, 2004
Sharpe B. Glucose Roller Coaster. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/glucose-roller-coaster
The Case
A 71-year-old woman with congestive heart failure was admitted to the hospital. Her medical history was
significant for dialysis-dependent, end-stage kidney d…
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/workplace-safety/Workplace-Safety-Hospitals-2022-1215-ENGLISH_508.pdf
January 01, 2022 - SOPS Workplace Safety Supplemental Items for Hospitals
SOPS® Workplace Safety Supplemental
Item Set for the SOPS Hospital Survey
Language: English
Purpose: This supplemental item set was designed for use with the core SOPS® Hospital Survey Version 2.0 to help
hospitals assess the extent to which their orga…
-
psnet.ahrq.gov/node/49659/psn-pdf
July 01, 2012 - Sloppy and Paste
July 1, 2012
Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/sloppy-and-paste
The Case
A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new
onset chest pain. The ED physician reviewed the patient's electronic me…
-
psnet.ahrq.gov/node/33840/psn-pdf
August 01, 2017 - ACGME's 2017 Revision of Common Program
Requirements
August 1, 2017
Malloy K, Brigham TP, Nasca TJ. ACGME's 2017 Revision of Common Program Requirements. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/perspective/acgmes-2017-revision-common-program-requirements
Perspective
The Accreditation Council for Graduate …
-
psnet.ahrq.gov/node/612828/psn-pdf
February 23, 2022 - Delayed Diagnosis of Kidney Transplant Complications
February 23, 2022
Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
Objectives
Recognition, early evaluation, and management of kidney …
-
psnet.ahrq.gov/node/49803/psn-pdf
January 01, 2018 - Point-of-care Mixup: 1 Shot Turns Into 3
August 1, 2017
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
The Case
A 2-month-old boy was brought in for a routine 2-month well-child visit. The exam was completed and the
app…
-
psnet.ahrq.gov/node/49617/psn-pdf
January 01, 2011 - Failure to Reevaluate
December 1, 2010
Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/failure-reevaluate
The Case
A 61-year-old woman receiving palliative chemotherapy for non–small-cell lung cancer at a community
hospital developed methicillin-resistant staphylococc…
-
psnet.ahrq.gov/node/49587/psn-pdf
May 01, 2009 - Missing Trauma
May 1, 2009
Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/missing-trauma
The Case
A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a
few minutes later by a customer, who immediately called 911. On arrival, para…
-
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-utah-state-snapshot.pdf
January 01, 2018 - Spotlight on Utah -- The National Evaluation of the CHIPRA Quality Demonstration Grant Program
January 2018
This brief highlights the major strategies, lessons learned,
and outcomes from Utah’s experience from February
2010 to February 2016 with the quality demonstration
funded by the Centers for Medicare & Medic…
-
psnet.ahrq.gov/node/49626/psn-pdf
May 01, 2011 - Outbreak
May 1, 2011
Rothman R, Stapleton S. Outbreak. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/outbreak
The Case
A 36-year-old healthy man developed an acute febrile illness associated with a vesicular rash. He
presented to an urgent care clinic where he was diagnosed with varicella infection ("chic…
-
www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/implementation-guides/implementation-guide1/impguide1app.html
March 01, 2019 - Appendix: Profiles of the CHIPRA Quality Demonstration States’ Stakeholder Engagement Initiatives
Implementation Guide Number 1
This Implementation Guide includes suggested steps and tips for implementing initiatives for improving child health care quality from the CMS-funded national evaluation of the Childr…
-
psnet.ahrq.gov/node/49471/psn-pdf
December 01, 2004 - Carpe Diem (Seize the Day)
December 1, 2004
Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/carpe-diem-seize-day
The Case
A 53-year-old man presented for a new patient visit at a local medical clinic. He had several chronic
medical conditions including hypertension, h…
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-200-tech-specs.pdf
December 14, 2011 - Technical Specifications and Chart Abstraction Tool
Age upon
Age upon admission
Patient ID Race Ethnicity Gender Payer
Preferred
Language
admission (YEARS)
[e.g. for 12.5 year
(MONTHS) [
e.g. for 12.5
old, years = 12) year old,
months = 6]
1 White Non-Hispanic Female Medicaid English 12 3
2 Black Non-his…
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/4-unc-webcast-fenton-wilhelm-amos.pdf
August 15, 2019 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Fenton-Wilhelm-Amos
U
N
C H E A L T H C A R E S Y S T E M
U
N
C H E A L T H C A R E
Culture of Safety Improvement Project
UNC Medical Center
29
U
N
C H …
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/family-slides.pptx
June 01, 2021 - Discussing Infectious Concerns About Residents With Family Members and Caregivers
Discussing Infectious Concerns About Residents With Family Members and Caregivers
Long-Term Care
AHRQ Safety Program for Improving Antibiotic Use
AHRQ Pub. No. 17(21)-0029
June 2021
Discussing Concerns With Family
1
Objectives
Review…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-facnotes.docx
May 01, 2017 - Module 5: Script and Slides
AHRQ Safety Program for Ambulatory Surgery
Management Practices for Sustainability
Module 5: Visual Management
AHRQ Safety Program for Reducing CAUTI in Hospitals
Facilitator Notes
SLIDE 1
Title: Management Practices for Sustainability; Module 5: Visual Management
SAY:
As mentioned in…
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/prescribers-slides.pptx
June 01, 2021 - PowerPoint Presentation
Communicating Infectious Concerns With Antibiotic Prescribers
Long-Term Care
AHRQ Safety Program for Improving Antibiotic Use
AHRQ Pub. No. 17(21)-0029
June 2021
Communicating With Prescribers
1
Objectives
Describe the components of, and when to use SBAR:
Situation
Background
Assessment …
-
psnet.ahrq.gov/node/49414/psn-pdf
September 01, 2003 - Making Do
September 1, 2003
Bradley LD. Making Do. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/making-do
The Case
A 56-year-old female with dysfunctional uterine bleeding and possible retained intrauterine device (IUD)
was scheduled for elective hysteroscopy and dilation and curettage (D&C). Of note, sh…
-
psnet.ahrq.gov/node/49826/psn-pdf
April 01, 2018 - Air on the Side of Caution
April 1, 2018
Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/air-side-caution
The Case
A young woman with morbid obesity was scheduled for cardiac catheterization to evaluate shortness of
breath and chest pain. A decision was m…