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  1. psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
    August 21, 2016 - Radiology Missed an Intracranial Bleed in a Lethargic Infant. Citation Text: Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation For…
  2. psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
    March 01, 2015 - SPOTLIGHT CASE Bad Writing, Wrong Medication Citation Text: Devine B. Bad Writing, Wrong Medication. 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…
  3. hcup-us.ahrq.gov/reports/race/StandAloneR_EExecSum4_28forweb.pdf
    March 11, 2011 - Microsoft Word - Stand Alone R-E Exec Sum 4-28 for web.docx 1 STATE DOCUMENTATION OF RACIAL AND ETHNIC HEALTH DISPARITIES TO INFORM STRATEGIC ACTION: SUMMARY Nearly a decade ago, the Institute of Medicine (IOM) issued a call to action to redesign the United States’ health care system because Americans do not …
  4. psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
    December 23, 2020 - SPOTLIGHT CASE Recurrent Hypoglycemia: A Care Transition Failure? Citation Text: Eytan T. Recurrent Hypoglycemia: A Care Transition Failure?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format:…
  5. digital.ahrq.gov/sites/default/files/docs/citation/r13hs028546-kennedy-final-report-2022.pdf
    January 01, 2022 - Improving Technology Innovation in Medicaid Programs – Final Report FINAL PROGRESS REPORT “Improving Technology Innovation in Medicaid Programs” Susan Kennedy, MPP, MSW, Senior Director AcademyHealth August 3, 2021-August 2, 2022 Sheena Patel, Federal Project Officer Agency for Healthcare Research and Qualit…
  6. psnet.ahrq.gov/perspective/conversation-paul-g-shekelle-md-mph-phd
    February 26, 2025 - In Conversation With… Paul G. Shekelle, MD, MPH, PhD October 1, 2011  Citation Text: In Conversation With… Paul G. Shekelle, MD, MPH, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862983/psn-pdf
    February 28, 2024 - Airway Obstruction during Anterior Cervical Spine Surgery February 28, 2024 Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery The Case A 47-year-old obese man (body weight 13…
  8. psnet.ahrq.gov/web-mm/peripheral-iv-too-long
    September 15, 2011 - SPOTLIGHT CASE Peripheral IV in Too Long Citation Text: Fang C-T. Peripheral IV in Too Long. 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 End…
  9. www.ahrq.gov/sites/default/files/2024-04/baernholdt-report.pdf
    January 01, 2024 - Final Progress Report: Care Interventions and Quality of Care in Rural and Urban Nursing Units Title of Project: Care Interventions and Quality of Care in Rural and Urban Nursing Units Principal Investigator and Team Members: PI: Marianne Baernholdt, PhD, MPH, RN, Virginia Commonwealth University, School of N…
  10. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/respiratory-slides.pptx
    November 01, 2019 - PowerPoint Presentation: Best Practices in the Diagnosis and Treatment of Community-Associated Lower Respiratory Tract Conditions Best Practices in the Diagnosis and Treatment of Community-Associated Lower Respiratory Tract Conditions Acute Care AHRQ Safety Program for Improving Antibiotic Use AHRQ Pub. No. 17(20)-00…
  11. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/respiratory-facilitator-guide.pdf
    November 01, 2019 - Best Practices in the Diagnosis and Treatment of Community-Associated Lower Respiratory Tract Conditions AHRQ Safety Program for Improving Antibiotic Use 1 AHRQ Pub. No. 17(20)-0028-EF November 2019 Best Practices in the Diagnosis and Treatment of Community-Associated Lower Respiratory T…
  12. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/ASB-UTI-slides.pptx
    November 01, 2019 - PowerPoint Presentation: Best Practices in the Diagnosis and Treatment of Asymptomatic Bacteriuria and Urinary Tract Infections Best Practices in the Diagnosis and Treatment of Asymptomatic Bacteriuria and Urinary Tract Infections Acute Care AHRQ Safety Program for Improving Antibiotic Use AHRQ Pub. No. 17(20)-0028-EF…
  13. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/gastro-slides.pptx
    November 01, 2019 - PowerPoint Presentation Best Practices in the Diagnosis and Treatment of Diverticulitis and Biliary Tract Infections Acute Care AHRQ Safety Program for Improving Antibiotic Use AHRQ Pub. No. 17(20)-0028-EF November 2019 Diverticulitis and Biliary Tract AHRQ Safety Program for Improving Antibiotic Use – Acute Care …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72689/psn-pdf
    January 29, 2021 - But See the Patient First January 29, 2021 Sinigayan VR. But See the Patient First. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/see-patient-first The Case   A 55-year-old man with acute myeloid leukemia presented to the emergency department (ED) with a chief complaint of fever. Five days previously, he …
  15. www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-13-measuring-and-benchmarking.pdf
    September 01, 2015 - Measuring and Benchmarking Clinical Performance Primary Care Practice Facilitation Curriculum Module 13: Measuring and Benchmarking Clinical Performance Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov …
  16. www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-32-self-management-support.pdf
    September 01, 2015 - Primary Care Practice Facilitation Curriculum Module 32: Improving Self-Management Support and Engaging Patients in Care and Practice Improvement Topics Primary Care Practice Facilitation Curriculum Module 32: Improving Self-Management Support and Engaging Patients in Care and Practice Improvement Topics …
  17. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/bacteremia-slides.pptx
    November 01, 2019 - Best Practices in the Diagnosis and Treatment of Bacteremia Best Practices in the Diagnosis and Treatment of Bacteremia Acute Care AHRQ Safety Program for Improving Antibiotic Use AHRQ Pub. No. 17(20)-0028-EF November 2019 Bacteremia AHRQ Safety Program for Improving Antibiotic Use – Acute Care 1 Objectives Rev…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49810/psn-pdf
    November 01, 2017 - Palliative Care: Comfort vs. Harm November 1, 2017 Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm Case Objectives Recognize errors may be difficult to identify in palliative care. State that medication errors and errors in communica…
  19. psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
    March 24, 2025 - In Conversation With… Rebecca Lawton, PhD September 1, 2018  Citation Text: In Conversation With… Rebecca Lawton, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation …
  20. www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter6.html
    August 01, 2022 - Designing Consumer Reporting Systems for Patient Safety Events Chapter 6. Discussion and Policy Implications Previous Page Next Page Table of Contents Designing Consumer Reporting Systems for Patient Safety Events Executive Summary Chapter 1. Background Chapter 2. Conceptual Framework and Desi…