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  1. Psn-Pdf (pdf file)

    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,…
  2. Psn-Pdf (pdf file)

    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…
  3. 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…
  4. 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 …
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. 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…
  9. 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…
  10. 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 …
  11. 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…
  12. 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…
  13. 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 …
  14. 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…
  15. 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 …
  16. 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…
  17. 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…
  18. 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…
  19. 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.
  20. 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