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psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
September 01, 2004 - SPOTLIGHT CASE
Unintended Consequences of CPOE
Citation Text:
Wears RL. Unintended Consequences of CPOE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - Delayed Breast Cancer Diagnosis: A False Sense of Security.
Citation Text:
Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/another-fall
June 01, 2010 - SPOTLIGHT CASE
Another Fall
Citation Text:
Bogardus SG. Another Fall. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
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psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
October 28, 2020 - Hospital-Acquired Diabetic Ketoacidosis.
Citation Text:
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
February 26, 2025 - In Conversation With… Tejal K. Gandhi, MD, MPH
April 1, 2014
Citation Text:
In Conversation With… Tejal K. Gandhi, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/49392/psn-pdf
April 01, 2003 - Another Fall
April 1, 2003
Bogardus SG. Another Fall. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/another-fall
Case Objectives
List risk factors for falls in hospitalized patients
Understand appropriate use of restraints
Identify system issues contributing to falls in hospitalized patients
Case & Comm…
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hcup-us.ahrq.gov/reports/statbriefs/sb144.pdf
August 01, 2011 - Overview of Hospital Stays in the United States, 2010
1
December 2012
Overview of Hospital Stays in the United
States, 2010
Anne Pfuntner, Lauren M. Wier, M.P.H., and Anne Elixhauser,
Ph.D.
Introduction
Inpatient hospital care is a significant component of the health
care system, account…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - SPOTLIGHT CASE
Delayed Diagnosis of Mesenteric Ischemia
Citation Text:
Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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…
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psnet.ahrq.gov/web-mm/challenging-case-multiple-suicide-attempts-complex-patient-psychiatric-comorbidities
September 27, 2023 - SPOTLIGHT CASE
Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities.
Citation Text:
Bourgeois JA, Xiong G. Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities.. PSNet [internet]. Rockville (MD): Agency for …
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psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adverse-events-during-transitions-care
September 09, 2013 - SPOTLIGHT CASE
Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care
Citation Text:
Lucier DJ, Greenwald JL. Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/node/72589/psn-pdf
December 23, 2020 - Delayed Breast Cancer Diagnosis: A False Sense of
Security.
December 23, 2020
Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
The Case
A 60-year-old woman was se…
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psnet.ahrq.gov/web-mm/wet-read
October 01, 2017 - SPOTLIGHT CASE
The Wet Read
Citation Text:
Arenson RL. The Wet Read. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/49753/psn-pdf
February 01, 2016 - Robotic Surgery: Risks vs. Rewards
February 1, 2016
Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
Case Objectives
Discuss the background and current trends in robotic surgery.
Identify the benefits of robotic s…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdf
January 01, 2005 - The test
of functional health literacy in adults: a new
instrument for measuring patients’ literacy skills
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/050-dec-implementation-notes.docx
October 01, 2024 - The training plan should align with the current knowledge and skills of the unit personnel, addressing
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www.ahrq.gov/sites/default/files/2025-03/blike-report.pdf
January 01, 2025 - Rasmussen J: Skills, rules, and knowledge; signals, signs, and symbols, and other distinctions in
human
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-health-systems-guidelines-development.pdf
February 01, 2019 - • To use such tools, the EPCs will need staff with informatics skills, and the Agency for
Healthcare
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cdsic.ahrq.gov/sites/default/files/2024-09/Final%20IAS%20PC%20CDS%20Case%20Studies%20Report_2.pdf
January 01, 2024 - Resources
• Lack of local clinician champion for intervention
• Clinicians with limited technical skills … Clinicians with Limited Technical Skills. … materials and other resources based on early use experience among clinicians with more technological
skills
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digital.ahrq.gov/sites/default/files/Final%20IAS%20PC%20CDS%20Case%20Studies%20Report_2.pdf
August 31, 2024 - Resources
• Lack of local clinician champion for intervention
• Clinicians with limited technical skills … Clinicians with Limited Technical Skills. … materials and other resources based on early use experience among clinicians with more technological
skills
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops101-webcast-transcript-ad.pdf
June 01, 2020 - SOPS™ 101 Webcast Transcript
November 2018 https://www.ahrq.gov/sops/index.html 1
Understanding SOPS Surveys: A Primer for New Users
October 23, 2018 – Webcast Transcript
Speakers:
Laura Gray, M.P.H.
Senior Study Director
User Network for the AHRQ Surveys on Patient Safety C…