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psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - Refused Medication Error
February 1, 2017
Foley M. Refused Medication Error. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was
alert to self and place only. The patient h…
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psnet.ahrq.gov/node/33633/psn-pdf
May 01, 2006 - Patient Safety in the Physician Office Setting
May 1, 2006
Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
Perspective
Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 …
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psnet.ahrq.gov/node/49796/psn-pdf
June 01, 2017 - Chest Tube Complications
June 1, 2017
Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/chest-tube-complications
The Case
A 30-year-old woman with a history of cystic fibrosis was admitted to the hospital for management of a
spontaneous left pneumothorax (coll…
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psnet.ahrq.gov/node/49746/psn-pdf
October 01, 2015 - An Obstructed View
October 1, 2015
Carter J. An Obstructed View. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/obstructed-view
The Case
A 66-year-old man with a history of benign prostatic hyperplasia and obstructive sleep apnea presented to
the emergency department (ED) with subacute abdominal pain that …
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psnet.ahrq.gov/node/49655/psn-pdf
June 01, 2012 - A Painful Dilemma
June 1, 2012
Davison SN. A Painful Dilemma. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/painful-dilemma
The Case
A 47-year-old woman with end-stage renal disease due to polycystic kidney disease was admitted with
fever. She was taking propoxyphene or hydrocodone at home for pain. She h…
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psnet.ahrq.gov/node/49629/psn-pdf
June 01, 2011 - Say It Again
June 1, 2011
Henriksen K, Hall KK. Say It Again. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/say-it-again
The Case
A 72-year-old man was admitted to the hospital with community-acquired pneumonia and hyponatremia.
During his third hospital night, the on-call physician was contacted by the c…
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psnet.ahrq.gov/node/49683/psn-pdf
April 01, 2013 - Acute Care Admission of the Behavioral Health Patient
April 1, 2013
Weiss AP, Rosenbaum JF. Acute Care Admission of the Behavioral Health Patient. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/acute-care-admission-behavioral-health-patient
The Case
A 25-year-old man presented to the emergency department (E…
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psnet.ahrq.gov/node/49572/psn-pdf
October 01, 2008 - Mistaken Identity
October 1, 2008
Hall LW. Mistaken Identity. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/mistaken-identity
The Case
An 85-year-old Cantonese-speaking woman was admitted to the medical service with altered mental status
and a reported fall. After finding tenderness in her left hip, the p…
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psnet.ahrq.gov/node/49533/psn-pdf
March 01, 2007 - Staggered Sensitivity Results
March 1, 2007
Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/staggered-sensitivity-results
The Case
A 60-year-old woman with squamous cell carcinoma of the glottis underwent laryngectomy, anterior neck
dissection, and pectoralis fla…
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psnet.ahrq.gov/web-mm/misplaced-vial-medication-kit-variability-contributes-medication-error-during-patient
March 12, 2021 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport
Citation Text:
MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Q…
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psnet.ahrq.gov/node/853080/psn-pdf
August 30, 2023 - Virtual Nursing: Improving Patient Care and Meeting
Workforce Challenges
August 30, 2023
Sanford K, Schuelke S, Lee M, et al. Virtual Nursing: Improving Patient Care and Meeting Workforce
Challenges. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workf…
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www.ahrq.gov/teamstepps-program/curriculum/communication/tools/index.html
July 01, 2023 - Section 2: Explanation of Key Concepts and Tools
This section contains explanations and illustrations to help you better understand and appreciate the importance of TeamSTEPPS communication concepts and tools. If you teach this content or want additional insights into how the material can be more fully learned,…
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www.ahrq.gov/teamstepps-program/curriculum/team/implement/teach-change.html
February 01, 2024 - Teaching Implementation Change Management
Change Management Overview and Objectives
Display Slide 63, “Change Management,” as the class reassembles before discussing the last implementation topic.
In discussing Slide 64, “Objectives,” as you transition from coaching to change management, note that succe…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-199-section-2-chart-tech-specs.pdf
January 01, 2013 - Section 2, Chart Abstraction Tool and Technical Specifications
Basic Elements
Age upon
Age upon admission
Patient ID Race Ethnicity Gender Payer
Preferred
Language
admission (YEARS)
[e.g. for 12.5 year
(MONTHS) [
e.g. for 12.5
old, years = 12) year old,
months = 6]
1 White Non-Hispanic Female Medicaid E…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/huddles/huddles-component-kit.docx
May 01, 2017 - Module 2: Component Kit
AHRQ Safety Program for Ambulatory Surgery
Management Practices for Sustainability
Module 2: Daily Huddles
AHRQ’s Safety Program for Ambulatory
Daily Huddle Component Kit
Contents
1. Why a Daily Huddle? 2
2. “Know What, Know How, Know Why” for Daily Huddle 4
3. Plan-Do-Study-Act “Ramp”: …
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www.ahrq.gov/hai/tools/mvp/modules/technical/nurse-early-mobility-protocols-fac-guide.html
January 01, 2017 - Nurse-Driven Early Mobility Protocols: Facilitator Guide
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: Nurse-Driven Early Mobility Protocols
Say:
This module will provide an overview of the interventions required for early mobility in mechanically ventilated patients and ways to esta…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/nursedr-early-mobility-protocols-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Nurse-Driven Early Mobility Protocols
SAY:
This module will provide an overview of the interventions required for early mobility in mechanically ventilated patients and ways to establish and sustain a…
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/169-cusp-science-safety-slides.pptx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
AHRQ Safety Program for MRSA Prevention
The Science of Safety:
Principles in Practice
ICU & Non-ICU
AHRQ Pub. No. 25-0007
October 2024
AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU
The Science of Safety
1
Educational Objectives
Describe the patient safety risks tha…
-
www.ahrq.gov/research/findings/final-reports/crctoolkit/crctool1a1.html
April 01, 2018 - Tracking and Improving Screening for Colorectal Cancer Intervention
1.a-1 Information Packet for Participating Practices
Previous Page Next Page
Table of Contents
Tracking and Improving Screening for Colorectal Cancer Intervention
I. Introduction
II. Background
III. Intervention Steps and Tool…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/patient-safety-slides.pptx
November 01, 2019 - Improving Antibiotic Use is a Patient Safety Issue
Making the Case That Improving Antibiotic Use Is a Patient Safety Issue
Acute Care
AHRQ Safety Program for Improving
Antibiotic Use
AHRQ Pub. No. 17(20)-0028-EF
November 2019
Improving Antibiotic Use – Patient Safety Issue
AHRQ Safety Program for Improving Antibio…