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psnet.ahrq.gov/node/49526/psn-pdf
December 01, 2006 - Crossing the Borderline
December 1, 2006
Oldham JM. Crossing the Borderline. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/crossing-borderline
The Case
A 24-year-old woman with borderline personality disorder was admitted to an inpatient psychiatry unit
following a failed suicide attempt with excess doses…
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psnet.ahrq.gov/node/73335/psn-pdf
May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition
Error
May 26, 2021
Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
The Case
A 4-year-old (former 33-week premature) boy with a …
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psnet.ahrq.gov/web-mm/critical-opportunity-lost
February 17, 2017 - Critical Opportunity Lost
Citation Text:
Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…
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psnet.ahrq.gov/node/49670/psn-pdf
November 01, 2012 - Missed Pneumonia
November 1, 2012
Rohde JM, Flanders S. Missed Pneumonia. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/missed-pneumonia
The Case
A 32-year-old man presented to the emergency department (ED) with 3 days of fever and right pleuritic
chest pain. Review of systems was negative for cough or dy…
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psnet.ahrq.gov/web-mm/or-peeping
May 01, 2015 - OR Peeping
Citation Text:
Mackenzie CF. OR Peeping. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hp/about/measures-hp50-2109.pdf
September 08, 2017 - Patient Experience Measures from the CAHPS Health Plan Survey
Patient Experience Measures from the CAHPS Health Plan Survey
CAHPS® Health Plan Survey and Instructions
Document No. 2109
Updated 9/8/2017
Patient Experience Measures from the
CAHPS® Health Plan Survey
Table of Contents
Introduction.…
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www.ahrq.gov/hai/tools/surgery/modules/on-boarding/data-into-action-fac-notes.html
December 01, 2017 - Turning Data Into Action—Using HSOPS and SSI Data as Part of a Meaningful Change: Facilitator Notes
AHRQ Safety Program for Surgery
Slide 1: Turning Data Into Action: Using HSOPS and SSI Data as Part of a Meaningful Change
Say:
In this module, you’ll learn about using data as part of your team’s improve…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/sppcii-facilitator-guide.docx
July 01, 2023 - Facilitator Guide for Hospital AIM Team Leads
Facilitator Guide for Hospital AIM Team Leads
What Is This Guide?
This guide is intended as a complement to the online training modules of the Safety Program for Perinatal Care II (SPPC-II) Teamwork Toolkit. It provides helpful information about scheduling and conducting …
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
July 01, 2023 - Patient and Family Engagement for Perinatal Safety: Facilitator Guide
AHRQ Safety Program for Perinatal Care
Slide 1: Patient and Family Engagement for Perinatal Safety
Say:
The Patient and Family Engagement module focuses on an important topic: making sure patients and their family members understand w…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_cord-prolapse.docx
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Sample Scenario for Umbilical Cord Prolapse In Situ Simulation
AHRQ Safety Program for Perinatal Care
Sample Scenario for Umbilical Cord Prolapse In Situ Simulation
Sample Scenario for Umbilical Cord Prolapse In Situ Simulation
Purpose of the tool: The Umbilical Cord Prolapse …
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/simulation-cord-prolapse.html
July 01, 2023 - Sample Scenario for Umbilical Cord Prolapse In Situ Simulation
AHRQ Safety Program for Perinatal Care
Purpose of the tool: The Umbilical Cord Prolapse In Situ Simulation tool provides a sample scenario for labor and delivery (L&D) staff to practice teamwork, communication, and technical skills in…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-north-carolina-state-snapshot.pdf
January 01, 2018 - Spotlight on North Carolina -- The National Evaluation of the CHIPRA Quality Demonstration Grant Program
January 2018
This brief highlights the major strategies, lessons learned,
and outcomes from North Carolina’s experience during the
quality demonstration funded by the Centers for Medicare
& Medicaid Services (…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/qi-action-slides.pptx
April 01, 2022 - Quality Improvement in Action Slides
Quality Improvement in Action
AHRQ Safety Program for Intensive Care Units:
Preventing CLABSI and CAUTI
AHRQ Pub. No. 17(22)-0019
April 2022
Objectives
Describe methods to identify your intensive care unit’s (ICU) focus area of improvement using quality improvement strategies
R…
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psnet.ahrq.gov/node/49641/psn-pdf
November 01, 2011 - Liver Failure After Chemotherapy: Did We Forget
Something?
November 1, 2011
Lubel J. Liver Failure After Chemotherapy: Did We Forget Something? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something
The Case
A 51-year-old Cantonese-speaking female with a his…
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psnet.ahrq.gov/node/49797/psn-pdf
June 01, 2017 - Diagnostic Overshadowing Dangers
June 1, 2017
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
The Case
A 72-year-old woman with history of opioid abuse was sent to the emergency department (ED) from a
methadone clinic because she a…
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psnet.ahrq.gov/node/49725/psn-pdf
January 01, 2015 - Haste Makes Care Unsafe
January 1, 2015
Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
The Case
An 80-year-old man with a history of coronary artery disease and atrial fibrillation underwent a combined
elective coronary artery bypass graft (CABG…
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psnet.ahrq.gov/node/72587/psn-pdf
December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric
Patients at Risk of Physiologic Instability
December 23, 2020
Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at
Risk of Physiologic Instability. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm…
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psnet.ahrq.gov/node/851158/psn-pdf
June 28, 2023 - Ventricular Wall Injury during a Diagnostic Cardiac
Catheterization
June 28, 2023
Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet].
2023.
https://psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
The Case
A patient was …
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psnet.ahrq.gov/node/49466/psn-pdf
October 14, 2004 - Hard to Swallow
October 1, 2004
Driver J. Hard to Swallow. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/hard-swallow
The Case
An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic
attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
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psnet.ahrq.gov/node/49815/psn-pdf
December 01, 2017 - Over-the-Counter Oversight
December 1, 2017
Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/over-counter-oversight
The Case
A 56-year-old man was evaluated in the burn clinic for a second-degree burn on his chest. Although
portions of his skin we…