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  1. psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
    June 16, 2021 - Looking for Meds in All the Wrong Places Citation Text: Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49580/psn-pdf
    March 21, 2009 - Medication Reconciliation Victory After an Avoidable Error March 21, 2009 Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error The Case A 91-year-old woman, previously active and indepen…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49614/psn-pdf
    November 01, 2010 - Reconciling Records November 1, 2010 Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/reconciling-records The Cases   Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local teaching hospital. When discharged, h…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33694/psn-pdf
    April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA April 1, 2010 In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba Editor's note: Janet M. Corrigan, PhD, MBA, is president and CEO of the National Quality Forum (NQF), a priva…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49465/psn-pdf
    December 22, 2021 - Electronic Err October 1, 2004 Tang PC. Electronic Err. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/electronic-err The Case A 75-year-old woman with coronary artery disease presented to the emergency department (ED) with chest pain that that had not responded to three sublingual nitroglycerin tablets at…
  6. psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
    March 30, 2016 - Chemotherapy Administration Safety Standards Citation Text: Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX En…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73549/psn-pdf
    July 28, 2021 - Local Anesthesia-Induced Coma During Total Knee Arthroplasty. July 28, 2021 Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty The Case A 61-year-old male patient weighing 57…
  8. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/002-cusp-learning-defects.pptx
    October 01, 2024 - AHRQ Safety Program for MRSA Prevention AHRQ Safety Program for MRSA Prevention Learning From Defects ICU & Non-ICU AHRQ Pub. No. 25-0007 October 2024 AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU Learning From Defects 1 Educational Objectives Describe a process to help teams learn from defects Explore …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49751/psn-pdf
    January 01, 2016 - New Patient Mistakenly Checked in as Another January 1, 2016 Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another The Case A 55-year-old man, presented to a primary care physician's office for an initial vis…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49836/psn-pdf
    July 01, 2018 - Primary Workaround, Secondary Complication July 1, 2018 Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication The Case A young adult with a progressive neurological disorder presented to a hospital emerg…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50843/psn-pdf
    January 29, 2020 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia January 29, 2020 Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia The Case A 54-year-old man was brought t…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49427/psn-pdf
    January 01, 2004 - Inadvertent Castration January 1, 2004 Calland FJ. Inadvertent Castration. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/inadvertent-castration The Case An 83-year-old man presented with a left groin mass, "which had been there for years" but had recently increased in size. The patient described persisten…
  13. psnet.ahrq.gov/web-mm/toxic-tachycardia
    March 01, 2005 - Toxic Tachycardia Citation Text: Wartofsky L. Toxic Tachycardia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49844/psn-pdf
    October 01, 2018 - Diffusion of Responsibility Leads to Danger October 1, 2018 Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger The Case A 70-year-old man was sent to the emergency department (ED) from a nursing facility…
  15. www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/co-nm-specialinnovation.html
    August 01, 2015 - Electronic Student Health Questionnaire (eSHQ) enhances risk assessment for adolescents Special Innovation Feature August 2015 Contents Summary Problems Addressed What the Staff Did Did It Work? Adoption Considerations Endnotes Learn More For More Information Summary The electronic S…
  16. www.ahrq.gov/hai/tools/mvp/modules/cusp/physician-staff-engagement-facguide.html
    March 01, 2017 - Physician and Staff Engagement: Facilitator Guide AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: Physician and Staff Engagement Say: Today, we will give you an overview of physician and staff engagement. Slide 2: Learning Objectives Say: After this session, you will be able to…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865467/psn-pdf
    March 27, 2024 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences March 27, 2024 Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferenc…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49782/psn-pdf
    January 01, 2017 - A Potent Medication Administered in a Not So Viable Route January 1, 2017 Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route The Case A 55-year-old man with history of nonischemic cardiomyop…
  19. www.ahrq.gov/hai/tools/mvp/modules/cusp/daily-goals-rounds-slides.html
    February 01, 2017 - Daily Goals During Interdisciplinary Rounds: Slide Presentation AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients Daily Goals During Interdisciplinary Rounds Slide 2: Learning Objectives After this session, you will be able to—…
  20. www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/part2-cancer.html
    May 01, 2018 - Chartbook for Hispanic Health Care Part 2: Trends in Priorities of the Heckler Report—Care for Cancer Previous Page Next Page Table of Contents Chartbook for Hispanic Health Care Acknowledgments Health Care For Hispanics National Quality Strategy Priorities: Patient Safety National Quality S…