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psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
March 27, 2024 - SPOTLIGHT CASE
"Do You Want Everything Done?": Clarifying Code Status
Citation Text:
Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/assemble/assembleteam.docx
June 02, 2025 - SAY:
The “Assemble the Team” module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit addresses CUSP team composition for your quality improvement initiative. This module will help you understand five concepts: the importance of teamwork and team composition to the CUSP initiative, developing a strategy …
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www.ahrq.gov/hai/cusp/modules/engage/exec-notes.html
December 01, 2012 - Engage the Senior Executive Facilitator Notes
CUSP Toolkit
The Engage the Senior Executive module of the CUSP Toolkit focuses on the role and responsibilities of the senior executive within the CUSP team. Engaging a senior executive to partner with a unit will bridge the gap between senior management and fron…
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - SPOTLIGHT CASE
Too Many Cooks in the Kitchen
Citation Text:
Dutton RP. Too Many Cooks in the Kitchen. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module2/facilitator-notes.docx
March 01, 2017 - Facilitator Notes
SAY:
The Senior Leader Engagement module focuses on the role and responsibilities of the senior leader within the facility safety team. Engaging a senior leader will bridge the gap between senior management and frontline providers, and will help to get a system-level perspective on safety challenge…
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psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - SPOTLIGHT CASE
Despite Clues, Failed to Rescue
Citation Text:
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - SPOTLIGHT CASE
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
Citation Text:
Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…
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psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
March 24, 2021 - SPOTLIGHT CASE
Pitfalls in Diagnosing Necrotizing Fasciitis
Citation Text:
Goh T, Goh LG. Pitfalls in Diagnosing Necrotizing Fasciitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/hEp2uYfD9KRhYTY5fGr8Tp
October 15, 2018 - Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: US Preventive Services Task Force Reaffirmation Recommendation Statement
Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum
US Preventive Services Task Force Reaffirmation
Recommendation Statement
US Preventive Services Task Force
T he US Preventive Servi…
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www.ahrq.gov/hai/pfp/hacrate2013.html
January 01, 2018 - 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013
Next Page
Table of Contents
2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013
Appendix
References
Summary
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hcup-us.ahrq.gov/reports/race/stand_alone_r_e_rpt.jsp
May 01, 2016 - State Documentation of Racial and Health Disparities to Inform Strategic Action: Summary
An official website of the Department of Health & Human Services
Search All AHRQ Websites
Careers
Con…
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psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
November 25, 2020 - Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.
Citation Text:
Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
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psnet.ahrq.gov/web-mm/room-without-orders
September 01, 2011 - SPOTLIGHT CASE
A Room Without Orders
Citation Text:
Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/8U8tcAjprBFpANg2GVAJVp
March 01, 2009 - Behavioral Counseling to Prevent Sexually Transmitted Infections: Recommendation Statement
Behavioral Counseling to Prevent Sexually Transmitted Infections:
U.S. Preventive Services Task Force Recommendation Statement
U.S. Preventive Services Task Force*
Description: New U.S. Preventive Services Task Force (USPSTF)
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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.
Citation Text:
Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
January 29, 2021 - Misconnection Leading to Arterial Thrombosis
Citation Text:
Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/patient-monitoring-systems-protocol.pdf
July 01, 2023 - EHC Protocol: Addressing Social Isolation To Improve Health of Older Adults: A Rapid Evidence Review
Evidence-based Practice Center Rapid Review Protocol
Project Title: Making Healthcare Safer (MHS) IV: Patient Monitoring Systems to
Prevent Failure to Rescue
Review Questions
Review Question: Based on t…
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psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 2024 - Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk
Citation Text:
Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quali…
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - SPOTLIGHT CASE
A Fatal Twist in Pseudohyperkalemia
Citation Text:
Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
February 05, 2020 - Hypoxic Gas Supply from Cross-Connected Pipelines
Citation Text:
Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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