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psnet.ahrq.gov/node/49635/psn-pdf
September 01, 2011 - Central, not Epidural
September 1, 2011
Simmons D. Central, not Epidural. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/central-not-epidural
The Case
A 55-year-old man with lung cancer recently had the lower lobe of his left lung removed. Post-operatively,
he was awake, alert, and oriented to time, place,…
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psnet.ahrq.gov/node/49510/psn-pdf
May 01, 2006 - Cups of Error
May 1, 2006
Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/cups-error
The Case
An 87-year-old man was 5 days postoperative from a decompressive laminectomy. Although he suffered
from dementia, he remained alert and oriented with only mild short-term memory…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/kit.html
June 01, 2017 - A Frontline Management System To Sustain Improvement in Safety Practices
Contents
1. Why a Frontline Management System?
2. Components of the Frontline Management System
3. Interactions of Components
4. Using the Model for Improvement
5. Additional Resources
1. Why a Frontline Management System?
M…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/data-change-slides.pptx
April 01, 2022 - Using Data To Drive Change and Improve Patient Safety Slides
Using Data To Drive Change and Improve Patient Safety
AHRQ Safety Program for Intensive Care Units:
Preventing CLABSI and CAUTI
AHRQ Pub. No. 17(22)-0019
April 2022
Objectives
Describe why data are critical to driving
improvement in your intensive care …
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psnet.ahrq.gov/node/49634/psn-pdf
September 01, 2011 - Situational (Un)Awareness
September 1, 2011
Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/situational-unawareness
The Case
A 75-year-old man was admitted on a Tuesday evening with abdominal pain, jaundice, and elevated liver
function tests, including a bi…
-
psnet.ahrq.gov/node/49697/psn-pdf
December 01, 2013 - Check the Anesthesia Machine
December 1, 2013
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/check-anesthesia-machine
The Case
A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension,
diabetes, sleep apnea…
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psnet.ahrq.gov/node/49387/psn-pdf
February 01, 2003 - Patient Mix-Up
February 1, 2003
Shojania KG. Patient Mix-Up. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/patient-mix
The Case
Joe Smith [not his real name], a 42-year-old man with nausea and vomiting for 4 days, was on the general
medical service at an academic medical center. Overnight, another man wit…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheetinstructions.pdf
June 02, 2025 - Prioritization Worksheet
Pediatric Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
Tool C.1 i
Prioritization Worksheet
What is the purpose of this tool? In today’s health care world, hospitals are required to take on
more responsibility than ever. With many different co…
-
www.ahrq.gov/prevention/resources/chronic-care/ccrm-atlas-suppl/ccrm-atlas3-6.html
October 01, 2013 - Potential Measures for Clinical-Community Relationships
Patient-Community Resource Relationships
Previous Page Next Page
Table of Contents
Potential Measures for Clinical-Community Relationships
Acknowledgements
Executive Summary
Introduction
Potential Measure Development Methodology
Poten…
-
www.ahrq.gov/prevention/resources/chronic-care/ccrm-atlas-suppl/ccrm-atlas3-3.html
October 01, 2013 - Potential Measures for Clinical-Community Relationships
Community Resource Element
Previous Page Next Page
Table of Contents
Potential Measures for Clinical-Community Relationships
Acknowledgements
Executive Summary
Introduction
Potential Measure Development Methodology
Potential Measures …
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/surgical/about/F2CGLizHoyRogerLevine.pdf
June 02, 2025 - Surgical Patient Experience of Care Survey Design Project
Surgical Patient Experience of Surgical Patient Experience of
Care Survey Design ProjectCare Survey Design Project
Elizabeth W. Hoy, MHA
Assistant Director, Regulatory Affairs
and Quality Improvement Programs
American College of Surgeons
OverviewOvervie…
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK3_T4-Letter_to_Prescribing_Clinicians.pdf
October 01, 2016 - Nursing Home
Antimicrobial Stewardship Guide
Determine Whether To Treat
Toolkit 3. Minimum Criteria for Common Infections Toolkit
Tool 4. Letter to Prescribing Clinicians on the Protocol for Three Common
Infections
PRINTED ON NURSING HOME OR MEDICAL DIRECTOR’S STATIONERY
[DATE]
[PRESCRIBING CLINICIAN…
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK3_T4-Letter_to_Prescribing_Clinicians.docx
October 01, 2016 - Tool 4. Letter to Prescribing Clinicians on the Protocol for Three Common Infections
PRINTED ON NURSING HOME OR MEDICAL DIRECTOR’S STATIONERY
[DATE]
[PRESCRIBING CLINICIAN NAME]
RECIPIENT ADDRESS
CITY, STATE ZIP]
Re: Change in protocol regarding three common infections and antibiotic stewardship
Dear Dr./Ms./Mr. [LAST …
-
digital.ahrq.gov/ahrq-funded-projects/using-health-information-technology-improve-transitions-complex-elderly
January 01, 2023 - Using Health Information Technology to Improve Transitions of Complex Elderly Patients from Skilled Nursing Facilities (SNF) to Home
Project Final Report ( PDF , 218.24 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are r…
-
psnet.ahrq.gov/topics-0
March 03, 2025 - Topics
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Featured Topics in Patient Safety
Updated Date: March 3, 2025
…
-
digital.ahrq.gov/ahrq-funded-projects/ehr-based-screening-and-intervention-intimate-partner-violence
January 01, 2024 - EHR-based Screening and Intervention for Intimate Partner Violence
Project Final Report ( PDF , 1.48 MB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/standalone_psi_casestudy.pdf
June 02, 2025 - Hospital Expands Use of AHRQ’s QI Toolkit To Improve Patient Safety Measures Prioritized by Medicare
Hospital Expands Use of AHRQ’s QI Toolkit To Improve Patient Safety
Measures Prioritized by Medicare
Abstract
Hospital
Harborview Medical Center (HMC),
a large, level I trauma center in
Seattle, Washington
L…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf
June 02, 2025 - Prioritization Worksheet
Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
i Tool C.1
Prioritization Worksheet
What is the purpose of this tool? In today’s health care world, hospitals are required to take on
more responsibility than ever. With many different competing p…
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/012-blood-culture-practices-webinar.docx
October 01, 2024 - Aware of this, the team schedules regular simulation training sessions.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
February 01, 2004 - nonsurgical
procedure
A procedure, either surgical or nonsurgical, done within the
office setting
Appointments … Transcribing 1 (2)
Dispensing 1 (2)
Administration 5 (11)
Surgical/nonsurgical procedures 2 (4)
Appointments … (Problem
type: Execution)
Appointments/follow-
up communication
with other providers
“Infant showed … (Problem type:
Mechanical/Technical Malfunction)
Administrative “The wrong appointment date was put