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psnet.ahrq.gov/node/49508/psn-pdf
January 01, 2007 - Language Barrier
April 1, 2006
Flores G. Language Barrier. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/language-barrier
The Case
A previously healthy 10-month-old girl was taken to a pediatrician's office by her monolingual Spanish-
speaking parents when they noted that their daughter had generalized we…
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psnet.ahrq.gov/node/33635/psn-pdf
July 01, 2006 - In Conversation with...Allan Frankel, MD
July 1, 2006
In Conversation with..Allan Frankel, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about how you became interested in this
kind of work.
Dr. Allan …
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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…
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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…
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psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - Antibiotics for URI/Sinusitis—A Simple Decision Gone
Bad
April 1, 2008
Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
Case Objectives
Understand the indications for antibiotic treatment in …
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - No News May Not Be Good News
August 1, 2012
Moore CR. No News May Not Be Good News. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
Case Objectives
Describe the frequency with which ambulatory test results are not followed up by providers.
Appreciate that inadequate follow-up of…
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psnet.ahrq.gov/web-mm/july-syndrome
July 01, 2011 - July Syndrome
Citation Text:
Young JQ. July Syndrome. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
D…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/4es-early-mobility-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
The Four Es of Early Mobility
SAY:
This module explains how to apply the Four Es of the TRIP framework to Early Mobility: engage, educate, execute, and evaluate.
Slide 1
Learning Objectives
SAY:
A…
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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…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-event-reporting-revised.docx
April 01, 2022 - CLABSI Event Reporting Tool
CAUTI Event Report Tool: Data for Event Analysis
This event report tool is designed to be used as a guide through the initial investigation for a defect analysis where the primary goal is to learn what happened and what factors may have contributed to the catheter-associated urinary trac…
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www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6s.html
June 01, 2014 - Care Coordination Measures Atlas Update
Chapter 6. Measure Maps and Profiles (continued, 20)
Previous Page Next Page
Table of Contents
Care Coordination Measures Atlas Update
Chapter 1: Background
Chapter 2. What is Care Coordination?
Chapter 3. Care Coordination Measurement Framework
Chapte…
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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-part1.pptx
March 01, 2017 - Antibiotic Stewardship Slides, Part 1: Hand Hygiene
How To Avoid the Harms of
Antibiotic Overuse
Training Module 4
AHRQ Pub. No. 16(17)-0003-21-EF
March 2017
AHRQ Safety Program for Long-term Care: HAIs/CAUTI
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
AHRQ SAFETY PROGRAM FOR LONG-TERM CARE: HAIs/CAUTI
…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm6.html
October 01, 2014 - Designing and Implementing Medicaid Disease and Care Management Programs
Section 6: Operating a Care Management Program
Previous Page Next Page
Table of Contents
Designing and Implementing Medicaid Disease and Care Management Programs
Introduction
Section 1: Planning a Care Management Program
…
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www.ahrq.gov/pqmp/implementation-qi/toolkit/tcd/qi-strategies.html
August 01, 2021 - Transcranial Doppler Ultrasonography (TCD) Screening Among Children with Sickle Cell Anemia Toolkit
Quality Improvement Strategies
Previous Page Next Page
Table of Contents
Transcranial Doppler Ultrasonography (TCD) Screening Among Children with Sickle Cell Anemia Toolkit
Introduction
Overview
…
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psnet.ahrq.gov/web-mm/communication-error-closed-icu
July 01, 2016 - Communication Error in a Closed ICU
Citation Text:
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar BibTeX EndNote X3 XML En…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/nicutoolkit.pdf
January 01, 2004 - Transitioning Newborns from NICU to Home: A Resource Toolkit
Transitioning Newborns
from NICU to Home:
A Resource Toolkit
Table of Contents
Overview: Improving the Quality of the Transition Home from the NICU............................1
Tools f…
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psnet.ahrq.gov/web-mm/other-side
May 01, 2007 - SPOTLIGHT CASE
The Other Side
Citation Text:
Vincent CA. The Other Side. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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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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www.ahrq.gov/sites/default/files/2024-12/danforth-report.pdf
January 01, 2024 - Final Progress Report: Electronic Clinical Surveillance To Measure and Improve Safety in Ambulatory Care
Final Progress Report
November 2019
Title
Electronic Clinical Surveillance to Measure and Improve Safety in Ambulatory Care
Principal Investigator and Team Members
Kim N. Danforth,1 Erin E. Hahn,1 Brian S. Mi…
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psnet.ahrq.gov/node/867985/psn-pdf
January 01, 2025 - Suicide Prevention
March 25, 2025
Boudreaux E, Gale B, Mossburg SE. Suicide Prevention. PSNet [internet]. 20024.
https://psnet.ahrq.gov/perspective/suicide-prevention
Introduction
Suicide is one of the leading causes of death in the United States, accounting for nearly 50,000 deaths in
2022, a 36% rise since 2000…