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meps.ahrq.gov/data_files/publications/cb3/cb3.shtml
May 01, 1999 - certification by Medicare and Medicaidcorresponded with the
implementation of revised certification requirements
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - Ambulatory Safety Nets to Reduce Missed and Delayed
Diagnoses of Cancer
July 31, 2023
https://psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
Summary
Concern over patient safety issues associated with inadequate tracking of test results has grown over the
last decade, a…
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - SPOTLIGHT CASE
What Happened on Telemetry?
Citation Text:
Sandau KE, Funk M. What Happened on Telemetry?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNo…
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psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
November 25, 2020 - SPOTLIGHT CASE
A Laceration that Needed a Proper Exam, Not an X-Ray
Citation Text:
Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - Unseen Perils of Urinary Catheters
Citation Text:
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar Bib…
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psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
September 27, 2023 - The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.
Citation Text:
Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depa…
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psnet.ahrq.gov/node/866261/psn-pdf
July 10, 2024 - Missed Compartment Syndrome after Steep Lithotomy
Position for Laparoscopic Gynecological Surgery
July 10, 2024
Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic
Gynecological Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/missed-compartment-syndrome…
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep
January 1, 2019
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
Case Objectives
List the patient safety events that are unique to in…
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx
Spotlight
Overdose of Gabapentin and Oxycodone in a Patient
with End-Stage Renal Disease: A Case for Appropriate
Interruptive Drug-Disease Alerts
Source and Credits
• This presentation is based on the January 2023 AHRQ WebM&M
Spotl…
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - Intubation Mishap
September 1, 2003
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/intubation-mishap
Case Objectives
To understand and apply a structured method of human factors case analysis
To describe the key components of effective teamwork
To understand the imp…
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017042-forrest-final-report-2011.pdf
January 01, 2011 - Improving Otitis Media Care with EHR-based Clinical Decision Support
Grant Final Report
Grant ID: R18HS17042
Improving Otitis Media Care with EHR-based Clinical
Decision Support
Inclusive Dates: 09/12/07 – 02/28/11
Principal Investigator:
Christopher B. Forrest, MD, PhD
Team Members:
…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/patient-safety-facilitator-guide.pdf
November 01, 2019 - Making the Case That Improving Antibiotic Use Is a Patient Safety Issue
AHRQ Safety Program for Improving
Antibiotic Use
1
AHRQ Pub. No. 17(20)-0028-EF
November 2019
Making the Case That Improving Antibiotic Use Is a Patient
Safety Issue
Acute Care
Slide Title and Commentary Slide Number…
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psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
February 26, 2025 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer
Save
Save to your library
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July 31, 2023
Innovation
Contact
…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cap-toolkit/cap_imptoolkit.pdf
January 01, 2018 - Community-Acquired Pneumonia Clinical Decision Support Implementation Toolkit Handbook
Community-Acquired
Pneumonia Clinical
Decision Support
Implementation
Toolkit
Handbook
1
Table of Contents
Introduction .................................................................................................…
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digital.ahrq.gov/sites/default/files/docs/behavior-change-slides-07172025.pdf
July 17, 2025 - Empowering Patients To Change Behavior Using Digital Healthcare Tools
Empowering Patients To Change Behavior Using
Digital Healthcare Tools
Presented by:
May May Leung, Ph.D., R.D.N.
David Dorr, M.D., M.S.
Moderated by:
Kevin Chaney, M.G.S.
Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Getting to the Root of the Matter
June 1, 2005
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/getting-root-matter
Case Objectives
Appreciate the goals and limitations of root cause analysis
Outline the steps to conduct root cause analysis
The Case
A…
-
psnet.ahrq.gov/node/849661/psn-pdf
June 28, 2023 - Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
June 28, 2023
Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During
Anesthesia for Emergency Cesarean Delivery. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/engaging-nurse-physician-patient.pptx
May 28, 2015 - Slide 1
Engaging The Nurse, Physician, Patient/Family; CUSP – Learn from Defects
Jenny Tuttle, RN, MSNEd, CNRN
Clinical Nurse Leader
Neuro/Medical/Surgical ICU
Tucson Medical Center
Tucson, Arizona
Christin Ko, MD, MBA, SFHM, FACP
Assistant Professor
Feinberg School of Medicine
Northwestern University
Chicago, IL
…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Learning From Defects in Care of Mechanically Ventilated Patients
SAY:
In this module, we will discuss the Learning From Defects tool. It is a very useful process that enables frontline staff to ident…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/actionplan-trip-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Action Plan for Translating Research Into Practice: Gap Analysis and Tests of Change
SAY:
This module will cover the Translating Research Into Practice (TRIP) framework. The TRIP framework lets us dig…