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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - SPOTLIGHT CASE
Discharged with IV antibiotics: When issues arise, who manages the complications?
Citation Text:
Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/pruprev-handouts.pdf
March 22, 2014 - On-Time Pressure Ulcer Prevention: Facilitator Training—Handouts
AHRQ’s Safety Program for Nursing Homes:
On-Time Pressure Ulcer Prevention
Facilitator Training
Handouts: Introduction to Pressure Ulcer Prevention
Reports
1. Nutrition Report: High Risk
2. Nutrition Report (Exercise)
3. Weight Summary Report
…
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psnet.ahrq.gov/node/836839/psn-pdf
March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare
Staff
March 31, 2022
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
Introduction
The…
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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - SPOTLIGHT CASE
Double Trouble
Citation Text:
Gurwitz JH. Double Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/nm2.jsp
July 01, 2016 - Standardizing the Collection of Race, Ethnicity, and Tribal Affiliation Data.
An official website of the Department of Health & Human Services
Search All AHRQ Websites
Careers
Contact Us
…
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psnet.ahrq.gov/node/860050/psn-pdf
January 04, 2024 - Radiology Missed an Intracranial Bleed in a Lethargic
Infant.
January 4, 2024
Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
The Case
A 2-month-old full-term male infant was b…
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psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
July 31, 2023 - Procedure Complications – Who is Responsible for Follow up?
Citation Text:
Chalupsky M, Wei H, Marquet E. Procedure Complications – Who is Responsible for Follow up?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
October 04, 2023 - The Hidden Danger of Unseen Intravenous Catheters
Citation Text:
Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs018183-weiner-final-report-2013.pdf
January 01, 2013 - Medication Reconciliation Technology to Improve Quality of Transitional Care - Final Report
Grant Final Report
Grant ID: R18HS018183
Medication Reconciliation Technology to Improve
Quality of Transitional Care
Inclusive Project Dates: 09/30/09 – 07/31/13
Principal Investigator:
Michael Weiner
Team Member…
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psnet.ahrq.gov/web-mm/customer-always-right
January 22, 2014 - SPOTLIGHT CASE
The "Customer" Is Always Right
Citation Text:
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - Medication Mix-Up: From Bad to Worse
Citation Text:
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/73455/psn-pdf
June 30, 2021 - Paroxysmal Supraventricular Tachycardia Masquerading
as Panic Attacks
June 30, 2021
Martin DT, O’Leary D. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
The Case
At the…
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psnet.ahrq.gov/web-mm/language-barrier
February 28, 2024 - Language Barrier
Citation Text:
Flores G. Language Barrier. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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…
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psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
May 19, 2021 - Hyperglycemia and Switching to Subcutaneous Insulin
Citation Text:
Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs020693-wexler-final-report-2014.pdf
January 01, 2014 - Use of HIT to Increase Primary Care Access in Medicaid Patients - Final Report
TITLE PAGE
Title of Project
Use of HIT to Increase Primary Care Access in Medicaid Patients
Principle Investigator and Team Members
PI: Randell K Wexler, MD, MPH
Co-I: Ann Scheck McAlea…
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psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
November 15, 2023 - Mother's Milk, but Whose Mother?
Citation Text:
Dougherty D. Mother's Milk, but Whose Mother?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - Wrong Catheter in the Right Patient
Citation Text:
Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - The Consequences of Miscommunication Regarding a
Possible Artifact
June 30, 2021
Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
Disclosure of Relevant Financial Relationships…
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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 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.
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psnet.ahrq.gov/web-mm/empty-handoff
August 01, 2017 - Empty Handoff
Citation Text:
Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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