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psnet.ahrq.gov/node/49829/psn-pdf
May 01, 2018 - Root Cause Analysis Gone Wrong
May 1, 2018
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
The Case
A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney
transplant. A suitabl…
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psnet.ahrq.gov/node/865778/psn-pdf
May 29, 2024 - Navigating Complications: The Unintended Journey of a
Guidewire During Dialysis Catheter Placement
May 29, 2024
Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis
Catheter Placement. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-complications-unint…
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www.ahrq.gov/sites/default/files/2024-09/fowler-report.pdf
January 01, 2024 - Final Progress Report: Determining a Learning Curve for Complex Laparoscopic Gastrointestinal Surgery
Title Page
Final Progress Report
Determining a Learning Curve for Complex Laparoscopic
Gastrointestinal Surgery
Principal Investigator: Dennis L. Fowler, MD, MPH
Co-Investigator: R. Todd Ogden, PhD
Co-Investigato…
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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.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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www.ahrq.gov/prevention/resources/depression/depsum1.html
April 01, 2013 - Screening for Depression in Adults
Summary of the Evidence
The summaries of the evidence briefly present evidence of effectiveness for preventive health services used in primary care clinical settings, including screening tests, counseling, and chemoprevention. They summarize the more detailed Systematic Evid…
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psnet.ahrq.gov/node/49570/psn-pdf
October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure?
October 1, 2008
Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
Case Objectives
Understand the complementary abilities of an electronic health record a…
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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…
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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:
…
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psnet.ahrq.gov/node/49588/psn-pdf
August 01, 2009 - Nurse Staffing Ratios: The Crucible of Money, Policy,
Research, and Patient Care
August 1, 2009
Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet
[internet]. 2009.
https://psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
Case…
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www.ahrq.gov/sites/default/files/2024-07/peters-report.pdf
January 01, 2024 - Final Progress Report: How Do Consumers View the Risks of Medical Errors?
FINAL REPORT
Title of Project: How Do Consumers View the Risks
of Medical Errors?
Principal Investigator: Ellen Peters
Team Member: Paul Slovic
Organization: Decision Research
Inclusive Dates of Project: 09/01/2001 – 08/31/2003
Federal …
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www.ahrq.gov/sites/default/files/2024-07/seid-sobo-report.pdf
January 01, 2024 - Final Progress Report: Managing the Health Needs of Vulnerable Children
Title of Project: Managing The Health Needs of Vulnerable Children
Principal Investigator and Team Members: Michael Seid, PhD, Elisa J. Sobo, PhD
Organization: Children’s Hospital Research Center
Inclusive Dates of Project: 9/30/2001 - 9/29/…
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psnet.ahrq.gov/node/49402/psn-pdf
June 01, 2003 - Inappropriate Antibiotic Use
June 1, 2003
Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
The Case
A 41-year-old woman presented to the hospital with acute renal failure, which came to be diagnosed as a
first presentation of s…
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psnet.ahrq.gov/node/865656/psn-pdf
April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous
Combination
April 24, 2024
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous
Combination. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
The Case
A 26-ye…
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psnet.ahrq.gov/node/49540/psn-pdf
August 21, 2007 - Resuscitation Errors: A Shocking Problem
August 21, 2007
Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
Case Objectives
Appreciate that delays in defibrillation can have significant negative effects on sur…
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psnet.ahrq.gov/node/42196/psn-pdf
May 15, 2013 - Prospective memory in the ICU: the effect of visual cues
on task execution in a representative simulation.
May 15, 2013
Grundgeiger T, Sanderson PM, Orihuela B, et al. Prospective memory in the ICU: the effect of visual cues
on task execution in a representative simulation. Ergonomics. 2013;56(4):579-89.
doi:10.10…
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hcup-us.ahrq.gov/datainnovations/clinicaldata/kickoffagenda_recreated.pdf
March 07, 2008 - Virginia Health Information
Adding Clinical Data to Statewide Administrative Data
Kickoff Meeting
March 7, 2008
Draft Agenda
8:30 AM
8:45 AM
Welcome and Introductions
Project Objectives,
Requirements, and Potential
Benefits to Participants
Michael Lundberg, Executive
Director, Virginia…
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effectivehealthcare.ahrq.gov/sites/default/files/lavallee-text.pdf
October 13, 2011 - Supporting Patient and Consumer Involvement in Patient-Centered Outcomes Research
…
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effectivehealthcare.ahrq.gov/sites/default/files/cf_intro_ehc_cf_overview_1012.pdf
October 13, 2011 - Slide 1
Community Forum
Supporting Patient and Consumer
Involvement in Patient-Centered
Outcomes Research
Danielle Lavallee
AHRQ Community Forum
October 13, 2011
Community Forum
Community Forum Community Forum
Provide a brief overview of the Agency for Healthcare Research and
Quality (AHR…
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psnet.ahrq.gov/node/35244/psn-pdf
December 17, 2008 - Representative case series from public hospital
admissions 1998 II: surgical adverse events.
December 17, 2008
Briant R, Morton J, Lay-Yee R, et al. Representative case series from public hospital admissions 1998 II:
surgical adverse events. N Z Med J. 2005;118(1219):U1591.
https://psnet.ahrq.gov/issue/representat…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/kHT3WGUaG2wTz2pF_ke7bn
Evidence Gaps Research Taxonomy Table: Screening for Osteoporosis to Prevent Fractures
1
Evidence Gaps Research Taxonomy Table
Research to Address Evidence Gaps in Preventive Services for the USPSTF
Topic: Screening for Osteoporosis to Prevent Fractures
To fulfill its mission to improve health by making…