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  1. Primary Workaround, Secondary Complication | PSNet

    psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
    January 24, 2018 - Primary Workaround, Secondary Complication Citation Text: Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar B…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49512/psn-pdf
    May 01, 2006 - Right? Left? Neither! May 1, 2006 Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/right-left-neither Case Objectives Appreciate the role of Reason's Swiss Cheese Model in medical errors Understand the process of analyzing a single error Provide suggestions for …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49640/psn-pdf
    November 01, 2011 - The Case for Patient Flow Management November 1, 2011 Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/case-patient-flow-management The Case A 52-year-old woman with a history of major depression, posttraumatic stress disorder, and alcohol abuse wa…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49529/psn-pdf
    February 01, 2007 - Crossed Coverage February 1, 2007 Kayser SR. Crossed Coverage. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/crossed-coverage The Case A 27-year-old woman with a history of congenital heart disease was admitted for cardiac transplantation evaluation. She had already undergone multiple surgeries, including…

  5. Abnormal Volunteer Results | PSNet

    psnet.ahrq.gov/web-mm/abnormal-volunteer-results
    July 18, 2016 - Abnormal Volunteer Results Citation Text: Fernandez C. Abnormal Volunteer Results. 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 Endnote ta…

  6. Hold That Order | PSNet

    psnet.ahrq.gov/web-mm/hold-order
    December 19, 2018 - Hold That Order Citation Text: Grissinger M. Hold That Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  7. PowerPoint Presentation

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/teach-back-slides-final508.pptx
    June 02, 2025 - PowerPoint Presentation Teach-Back AHRQ Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families The Agency for Healthcare Research and Quality, or AHRQ, funded the development of a Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families. A…

  8. SOPS® Value and Efficiency Supplemental Items for the SOPS Hospital Survey - Spanish (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/spanish-hospital-ve-supp-item-set-2022.pdf
    January 01, 2022 - SOPS® Value and Efficiency Supplemental Items for the SOPS Hospital Survey - Spanish SOPS® Value and Efficiency Supplemental Item Set for the SOPS Hospital Survey 2.0 Language: Spanish • Purpose: This supplemental item set was designed for use with the core SOPS® Hospital Survey Version 2.0 to help hospitals as…

  9. The Science of Improving Patient Safety and Identifying Defects: Facilitator Notes | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
    December 01, 2017 - The Science of Improving Patient Safety and Identifying Defects: Facilitator Notes AHRQ Safety Program for Surgery Slide 1: The Science of Improving Patient Safety and Identifying Defects Say: The topic of this module is the science of patient safety. The discussion will include the importance of unders…

  10. Safe Medication Administration: Slide Presentation | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/safe-medication-slides.html
    July 01, 2023 - Safe Medication Administration: Slide Presentation AHRQ Safety Program for Perinatal Care Slide 1: AHRQ Safety Program for Perinatal Care Safe Medication Administration Slide 2: Learning Objectives Image: Four ascending steps show the learning objectives: Define high-alert medications. Identif…

  11. Sample Scenario for Shoulder Dystocia In Situ Simulation | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/simulation-shoulder-dystocia.html
    July 01, 2023 - Sample Scenario for Shoulder Dystocia In Situ Simulation AHRQ Safety Program for Perinatal Care Purpose of the tool: The Shoulder Dystocia In Situ Simulation tool provides a sample scenario for labor and delivery (L&D) staff to practice teamwork, communication, and technical skills in the unit wh…

  12. Module-7-Slides (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-7-slides.pdf
    November 18, 2021 - Troubleshooting Your Automatic Referral System Module 7 S h e r r i e K h a d a n g a , M D a n d L a u r a L u i , M S PURPOSE TAKEheart Training and Technical Assistance Co mponents Training sessions guided by the Million Hearts®/AACVPR Ca…

  13. Antibiotic Stewardship Slides, Part 2

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/urine-culturing/antibiotic-stewardship/abx-stewardship-part2.pptx
    March 01, 2017 - Antibiotic Stewardship Slides, Part 2 Antibiotic Stewardship AHRQ Pub. No. 16(17)-0003-22-EF March 2017 AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Welcome to today’s educational session on antibiotic stewardship. This module is part of the Agency for Healthcare Research and Quality (or AHRQ) Safety Progra…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49489/psn-pdf
    September 01, 2005 - Double Trouble September 1, 2005 Gurwitz JH. Double Trouble. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/double-trouble Case Objectives Appreciate the incidence of adverse drug events in older persons List preventative measures that can be used to minimize medication errors in this population Encourage…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33642/psn-pdf
    November 01, 2006 - In Conversation With...Donald A. Norman, PhD November 1, 2006 In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background. How did you become interested…

  16. 40 of K | PSNet

    psnet.ahrq.gov/web-mm/40-k
    January 12, 2011 - 40 of K Citation Text: Lesar TS. 40 of K. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Cita…

  17. Misdiagnosis of a Pelvic Mass versus Pregnancy | PSNet

    psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy
    November 25, 2020 - Misdiagnosis of a Pelvic Mass versus Pregnancy Citation Text: Leiserowitz GS, Herding H. Misdiagnosis of a Pelvic Mass versus Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google …

  18. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
    August 01, 2022 - Module 4: Event Reporting, Event Investigation and Analysis AHRQ Communication and Optimal Resolution Toolkit Facilitator Notes Say: Module 4 of the CANDOR Toolkit covers the Event Reporting, Event Investigation, and Analysis component of the CANDOR process. Slide 1 Say: Obje…

  19. Cost of Disparities Fact Sheet (pdf file)

    hcup-us.ahrq.gov/reports/race/ReportcardsIB.pdf
    September 26, 2011 - Cost of Disparities Fact Sheet MAINTAIN AND EXPAND THE HEALTHCARE COST AND UTILIZATION PROJECT (HCUP) Contract No. HHSA-290-2006-00009-C September 26, 2011 Prepared by: Carrie Hanlon, MA Submitted to: Submitted by: Jenny Schnaier, Project Officer …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838972/psn-pdf
    October 27, 2022 - The Unhappy Patient Leaves Against Medical Advice. October 27, 2022 Nichols A. The Unhappy Patient Leaves Against Medical Advice. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice The Case A 61-year-old woman was placed on bedrest following major surgery. Her posto…
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