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  1. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
    January 01, 2021 - Spotlight Spotlight Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough Source and Credits • This presentation is based on the April 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Verna Gibbs, MD o AHRQ W…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49600/psn-pdf
    April 01, 2010 - Bad Writing, Wrong Medication April 1, 2010 Devine B. Bad Writing, Wrong Medication. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/bad-writing-wrong-medication Case Objectives Differentiate between a medication error and an adverse drug event. Appreciate the system complexities involved in medication erro…
  3. psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
    October 19, 2022 - SPOTLIGHT CASE Resuscitation Errors: A Shocking Problem Citation Text: Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: …
  4. psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
    October 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue Citation Text: Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Cit…
  5. psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
    November 01, 2003 - CVC Placement: Speak Now or Do Not Use the Line Citation Text: Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar …
  6. psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
    November 01, 2023 - Inadequate Preanesthetic Evaluation, Airway Trouble Citation Text: Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar …
  7. effectivehealthcare.ahrq.gov/sites/default/files/carman-presentation.pdf
    May 29, 2025 - Carman-notes-151021 copy-Teresa We got invited to submit a publication to Health Affairs in 2013 that really asked us to think, “How do we think about patient and   family engagement? How can  we think about what are the major issues in  this area?” We've been   thinking about this concept for a long time, …
  8. digital.ahrq.gov/sites/default/files/docs/publication/r21hs021581-goodney-final-report-2015.pdf
    January 01, 2015 - Leveraging Health Information Technology to Avoid Unnecessary Asymptomatic Carotid Revascularization - Final Report 1. Title Page: Title: Leveraging Health IT to Avoid Unnecessary Asymptomatic Carotid Revascularization Principal Investigator: Philip P. Goodney, MD, MS Organizati…
  9. psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
    October 02, 2019 - Continuity Errors in Resident Clinic Citation Text: Warm EJ. Continuity Errors in Resident Clinic. 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 …
  10. psnet.ahrq.gov/web-mm/discharging-our-responsibility
    January 16, 2019 - Discharging Our Responsibility Citation Text: Fonarow GC. Discharging Our Responsibility. 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 End…
  11. psnet.ahrq.gov/web-mm/picking-cause-stroke
    August 07, 2024 - Picking Up the Cause of the Stroke Citation Text: Chopra V. Picking Up the Cause of the Stroke. 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 X…
  12. psnet.ahrq.gov/web-mm/more-treatment-better-care
    August 11, 2021 - More Treatment—Better Care? Citation Text: Redberg R. More Treatment—Better Care?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
  13. 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…
  14. psnet.ahrq.gov/web-mm/harm-alarm-fatigue
    February 14, 2018 - SPOTLIGHT CASE Harm From Alarm Fatigue Citation Text: Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…
  15. psnet.ahrq.gov/web-mm/good-catch-operating-room
    August 27, 2017 - Good Catch in the Operating Room Citation Text: Day J, Paige JT. Good Catch in the Operating Room. 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 …
  16. psnet.ahrq.gov/web-mm/too-tight-control
    March 20, 2013 - SPOTLIGHT CASE Too Tight Control Citation Text: Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…
  17. hcup-us.ahrq.gov/datainnovations/clinicalcontentenhancementtoolkit/ny14.pdf
    March 20, 2012 - FAQs for Using Clinically Enhanced Claims Data to Guide Selection of Coronary Procedures NYSDOH Updated FAQs March 20, 2012 Page 1 New York State Department of Health Using Clinically Enhanced Claims Data to Guide Selection of Coronary Procedures Frequently Asked Questions and Answers 1. What is th…
  18. psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
    March 07, 2012 - Liver Biopsy: Proceed With Caution Citation Text: Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …
  19. hcup-us.ahrq.gov/reports/natstats/his96/table2b.htm
    January 01, 1996 - Hospital Inpatient Statistics, 1996 Table 2 (continued). Statistics for 1996 HCUP Nationwide Inpatient Sample, by multi-level CCS procedure (principal procedure only) ___________________________________________________________________________________________________________________________________________…
  20. hcup-us.ahrq.gov/datainnovations/clinicaldata/SampleVHIandhospitalcontractforAHRQstudy.pdf
    September 30, 2007 - SUBCONTRACTOR AGREEMENT CLINICAL DATA SHARING AGREEMENT THIS CLINICAL DATA SHARING AGREEMENT (this “Agreement”) is entered into as of the ___ day of ___________, 2008, by and between Virginia Health Information, Inc., a Virginia nonstock corporation (“VHI”) and XXXX), and recites and provides as follows: …