-
psnet.ahrq.gov/node/49450/psn-pdf
June 01, 2004 - The Wrong Shot: Error Disclosure
June 1, 2004
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
Case Objectives
Describe the rationale for disclosing harmful errors to patients.
Describe the specific information that patie…
-
psnet.ahrq.gov/node/49654/psn-pdf
June 01, 2012 - Transfer Troubles
June 1, 2012
Hains IM. Transfer Troubles. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfer-troubles
Case Objectives
Recognize that transfer of patients between hospitals is common.
Understand the frequency of errors and adverse events in the transfer of patients between hospitals.
…
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/cap-guide.docx
September 01, 2022 - The “Usually Antibiotics” Diagnoses: Community-Acquired Pneumonia – Facilitator Guide
AHRQ Safety Program for Improving Antibiotic Use
1
The “Usually Antibiotics” Diagnoses: Community-Acquired Pneumonia
Ambulatory Care
Slide Title and Commentary
Slide Number and Slide
The “Usually Antibiotics” Diagnoses: Commun…
-
psnet.ahrq.gov/node/49642/psn-pdf
December 01, 2011 - Order Interrupted by Text: Multitasking Mishap
December 1, 2011
Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
Case Objectives
State the prevalence of mobile devices among clinicians and their common health…
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/uti-slides.pptx
September 01, 2022 - Best Practices in the Diagnosis and Treatment of Asymptomatic Bacteriuria and Urinary Tract Infections – Slides
Best Practices in the Diagnosis and Treatment of Asymptomatic Bacteriuria and Urinary Tract Infections
Ambulatory Care
AHRQ Safety Program for Improving Antibiotic Use
AHRQ Pub. No. 17(22)-0030
Sep…
-
www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/mod1.html
February 01, 2023 - Preventing CAUTI in the ICU Setting: Facilitator’s Guide
Module 1: Overview
Previous Page Next Page
Table of Contents
Preventing CAUTI in the ICU Setting: Facilitator’s Guide
Introduction
Module 1: Overview
Module 2: Urinary Catheter Maintenance
Module 3: Conversations Around Device Necessit…
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/influenza-rsv-slides.pptx
September 01, 2022 - The Never Antibiotics Diagnoses: Influenza and RSV – Slides
AHRQ Safety Program for Improving Antibiotic Use
The “Never Antibiotics” Diagnoses:
Influenza and RSV
Ambulatory Care
AHRQ Pub. No. 17(22)-0030
September 2022
Influenza and RSV
AHRQ Safety Program for Improving Antibiotic Use – Ambulatory Care
1
Obje…
-
psnet.ahrq.gov/node/49828/psn-pdf
May 01, 2018 - Out of Sight, Out of Mind: Out-of-Office Test Result
Management
May 1, 2018
Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
Case Objectives
Recognize the general responsibilities of…
-
psnet.ahrq.gov/node/49543/psn-pdf
September 01, 2007 - Medication Reconciliation: Whose Job Is It?
September 1, 2007
Poon EG. Medication Reconciliation: Whose Job Is It? PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
Case Objectives
Appreciate the prevalence and impact of medication discrepancies at times of transition in …
-
www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/practice-survey-part2-mw.pdf
June 02, 2025 - H3 Practice Survey, Part 2
1
H3 Practice Survey, Part 2
H3 Baseline Practice Survey
Part 2
We appreciate your taking the time to complete Part 2 of the H3 baseline survey. This should take 10-
15 minutes to complete and has 3 sections. Remember, we only need one person at each practice to
complete thi…
-
psnet.ahrq.gov/node/49699/psn-pdf
February 01, 2014 - Multifactorial Medication Mishap
February 1, 2014
Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
Case Objectives
Understand the system-based causes of medication errors.
Describe a model for a systems approach to error analysis.
Id…
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-81-pgh-7-bibliography.pdf
January 01, 2016 - CHIPRA 81: Bibliography
1
0081 Bibliography
Ben-Arieh A. The child indicators movement: Past present, and future. Child Ind Res 2008; 1:3-
16.
Aday LA, Lee ES, Spears, B, et al. Health insurance and utilization of medical care for children
with special health care needs. Med Care 1993; 31(11):1013-26.…
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/manage-resident-RTI-facilitator-guide.docx
June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use
1
Management of a Resident With a Suspected Respiratory Tract Infection
Long-Term Care
Slide Title and Commentary
Slide Number and Slide
Management of a Resident With a Suspected Respiratory Tract Infection
Long-Term Care
SAY:
Welcome to this presentation, ti…
-
psnet.ahrq.gov/node/49606/psn-pdf
August 01, 2010 - Weighing In on Surgical Safety
August 1, 2010
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/weighing-surgical-safety
Case Objectives
Identify the comorbidites associated with obesity that place patients at higher risk for surgical
complications.
Un…
-
psnet.ahrq.gov/node/49485/psn-pdf
August 29, 2024 - Blind Spot
June 1, 2005
Lee LA. Blind Spot. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/blind-spot
The Case
A 36-year-old woman with no significant past medical history underwent right nephrectomy in the left lateral
position. The surgery was uncomplicated—her blood pressures intraoperatively were withi…
-
psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…
-
psnet.ahrq.gov/node/867475/psn-pdf
February 26, 2025 - From Pain Relief to Risk: A Case of Suspected Opioid
Overdose in a Pediatric Patient
February 26, 2025
Markham K, Usui M, Smith C. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a
Pediatric Patient. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overd…
-
psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - Getting the Diagnosis Both Right and Wrong
Citation Text:
Olson AP. Getting the Diagnosis Both Right and Wrong. 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…
-
psnet.ahrq.gov/node/49584/psn-pdf
April 01, 2009 - EMR Entry Error: Not So Benign
April 1, 2009
Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
The Case
A 47-year-old man with advanced AIDS was admitted to an academic medical center with a chief complaint
of shortness of breath. He was …
-
psnet.ahrq.gov/node/49678/psn-pdf
March 01, 2013 - A Weighty Mistake
March 1, 2013
Bokser SJ. A Weighty Mistake. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/weighty-mistake
Case Objectives
Understand factors associated with weight-based dosing medication errors in pediatric populations.
Describe how adoption of computerized provider order entry (CPOE) s…