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psnet.ahrq.gov/node/846935/psn-pdf
March 29, 2023 - Maternal Safety and Perinatal Mental Health
March 29, 2023
Allen C, Van CM, Mossburg S. Maternal Safety and Perinatal Mental Health . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
Maternal patient safety is a critical aspect of healthcare given the complex pr…
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psnet.ahrq.gov/node/49575/psn-pdf
November 01, 2008 - Sick and Pregnant
November 1, 2008
El-Ibiary S. Sick and Pregnant. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/sick-and-pregnant
The Case
A 35-year-old woman with chronic asthma presented to the emergency department (ED) with difficulty
breathing. The patient informed the staff that she was 17 weeks pre…
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psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
January 01, 2021 - Spotlight
Spotlight
The Consequences of Miscommunication
Regarding a Possible Artifact
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Kriti Gwal, MD
o AHRQ WebM&M Edit…
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psnet.ahrq.gov/node/49709/psn-pdf
May 01, 2014 - Raise the Bar
May 1, 2014
Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/raise-bar
The Case
A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The
patient was seen and evaluated by an anesthesiologist who was new to the cente…
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psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - Is It Safe to Be Direct?
Citation Text:
Kulkarni NS, Williams M. Is It Safe to Be Direct?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
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digital.ahrq.gov/electronic-prescribing-0
January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…
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psnet.ahrq.gov/web-mm/missed-tb
March 03, 2010 - Missed TB
Citation Text:
FitzGerald MJ, Menzies D. Missed TB. 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
…
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psnet.ahrq.gov/node/49836/psn-pdf
July 01, 2018 - Primary Workaround, Secondary Complication
July 1, 2018
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
The Case
A young adult with a progressive neurological disorder presented to a hospital emerg…
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psnet.ahrq.gov/node/49680/psn-pdf
March 01, 2013 - Pathologic Mistake
March 1, 2013
Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/pathologic-mistake
The Case
A 32-year-old previously healthy woman experienced abdominal pain and bloating for 6 months. The
discomfort worsened with eating. After losing 15 pounds …
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psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
Discharged with IV antibiotics:
When issues arise, who manages
the complications?
Source and Credits
• This presentation is based on the February 2020 AHRQ
WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Monica Donnel…
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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/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medmanagement_webinar_slides.pdf
January 01, 2015 - Medication Management
1
Medication Management
AHRQ
Guide to Improving Patient Safety in Primary
Care Settings by Engaging Patients and
Families
Speaker
Kelly Smith, PhD
Scientific Director, Quality & Safety
Co-PI, AHRQ Guide to Improve Patient Safety
in Primary Care Settings by Engaging
Patients …
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/aom-children-slides.pptx
September 01, 2022 - The “Sometimes Antibiotics” Diagnoses: Acute Otitis Media in Children – Slides
AHRQ Safety Program for Improving Antibiotic Use
The "Sometimes
Antibiotics" Diagnoses:
Acute Otitis Media in Children
Ambulatory Care
AHRQ Pub. No. 17(22)-0030
September 2022
Otitis Media
AHRQ Safety Program for Improving Antibiot…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/painmgmt-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Evidence Behind Pain, Agitation, and Delirium: Assessments and Sedation Management
SAY:
In this module, you will learn about the evidence behind pain, agitation, and delirium. You will also learn abou…
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www.ahrq.gov/hai/tools/mvp/modules/technical/daily-care-processes-slides.html
January 01, 2017 - Measure Descriptions for Daily Care Processes: Slide Presentation
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients
Measure Descriptions for Daily Care Processes
Slide 2: Learning Objectives
After this session, you will be abl…
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www.ahrq.gov/hai/tools/mvp/modules/technical/intro-early-mobility-slides.html
February 01, 2017 - Introduction and Evidence for Early Mobility: A Protocol To Get Patients Out of Bed Faster: Slide Presentation
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients
Introduction and Evidence for Early Mobility: A Protocol To Get Patients…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/nursedr-early-mobility-protocols-slides.pptx
January 01, 2017 - Presentation: Program Overview
Nurse-Driven Early Mobility Protocols
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-52-EF
January 2017
Nurse-Driven Early Mobility ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
SAY:
You have embarked on a unique journey.
1
Lear…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/indwelling-urinary-catheteruse/catheter-insertion/unlicensed-staff/unlicensed-catheter.pptx
March 01, 2017 - Catheter Types and Being Part of the Insertion Team
Urinary Catheter Types and
Care for Residents With Catheters
AHRQ Pub. No. 16(17)-0003-11-EF
March 2017
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Welcome to today’s session on how to care for residents with urinary catheters. This training is part of …
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www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual/procedure-manual-section-7-formulation-task-force-recommendations
June 21, 2025 - Procedure Manual Section 7. Formulation of Task Force Recommendations
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Table of Contents
7.1 General Principles for Making Recommendations
7.2 Recommendation Grades
7.…
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psnet.ahrq.gov/node/33582/psn-pdf
September 15, 2024 - Detection of Safety Hazards
September 15, 2024
Detection of Safety Hazards. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/detection-safety-hazards
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient s…