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www.ahrq.gov/sites/default/files/2025-05/mello-thoms-report.pdf
January 01, 2025 - Final Progress Report: MammoTutor: An Internet-Based Computer Tutoring System to Teach General Radiologists the Early Signs of Breast Cancer
Title of Project:
MammoTutor: An Internet-Based Computer Tutoring System to Teach General
Radiologists the Early Signs of Breast Cancer
Principal Investigator and Team Member…
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psnet.ahrq.gov/node/33668/psn-pdf
May 01, 2008 - In Conversation with…David W. Bates, MD, MSc
May 1, 2008
In Conversation with…David W. Bates, MD, MSc. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
Editor's note: Dr. David Bates is a Professor at Harvard Medical School, Medical Director of Clinical and
Quality …
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psnet.ahrq.gov/node/49676/psn-pdf
February 01, 2013 - Death by PCA
February 1, 2013
Hicks RW. Death by PCA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/death-pca
The Case
A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an
uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
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psnet.ahrq.gov/node/865376/psn-pdf
March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a
Patient Admitted for Leg Fractures
March 27, 2024
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…
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psnet.ahrq.gov/node/854848/psn-pdf
October 31, 2023 - Delay in Malignancy Diagnosis Reflects Systemic Failures
October 31, 2023
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
The Case
A 32-year-old man presented to the hospital with…
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psnet.ahrq.gov/node/49633/psn-pdf
September 01, 2011 - The Safety and Quality of Long Term Care
September 1, 2011
Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
Case Objectives
Identify commonly reported adverse events in long-term care.
Identify two to three challenges…
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www.ahrq.gov/sites/default/files/2025-03/smith2-report.pdf
January 01, 2025 - Final Progress Report: A Study of Narrative as the Cognitive Process Underlying Diagnostic Reasoning
A Study of Narrative as the Cognitive Process Underlying Diagnostic Reasoning
PI: Curtis Scott Smith, MD
Team: Chris Francovich, EdD
Magdalena Morris, RN, MSN
Andrew Turner, PhD
Bruce Robbins, PhD
Lynne Robins, …
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www.ahrq.gov/sites/default/files/2024-10/smucker-report.pdf
January 01, 2024 - Final Progress Report: Patient Safety in Hospice Care
AHRQ Grant Final Progress Report
Title of Project: Patient Safety in Hospice Care
Principal Investigator: Douglas R. Smucker, MD, MPH, Adjunct Professor, University
of Cincinnati Department of Family and Community Medicine
Team Members:
• Nancy Elder, MD, Ass…
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psnet.ahrq.gov/node/49482/psn-pdf
May 01, 2005 - Pregnant With Danger
May 1, 2005
Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pregnant-danger
The Case
A 35-year-old woman, 38 weeks pregnant, presented to the emergency department (ED) in the middle of
the night complaining of left leg pain. She also had so…
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www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily4.html
July 01, 2018 - Guide to Patient and Family Engagement
Summary and Discussion
Previous Page Next Page
Table of Contents
Guide to Patient and Family Engagement
Executive Summary
Introduction
Methods
Findings
Implications for the Guide
Summary and Discussion
Next Steps
References
Appendix A: Draft K…
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psnet.ahrq.gov/node/50949/psn-pdf
February 26, 2020 - Pre-analytical pitfalls: Missing and mislabeled specimens
February 26, 2020
Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
The Case
Case #1:
A 56-year-old man was admitted to…
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psnet.ahrq.gov/node/49480/psn-pdf
May 01, 2005 - Diagnosing Diagnostic Mistakes
May 1, 2005
McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
Learning Objectives
Understand the biases that may contribute to overcalling medical errors
Describe the impact of conside…
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www.ahrq.gov/hai/tools/mvp/modules/technical/intro-daily-care-facguide.html
February 01, 2017 - Introduction to Daily Care Processes: Evidence Behind Spontaneous Awakening Trials, Spontaneous Breathing Trials, and Head of Bed Elevation: Facilitator Guide
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: Introduction to Daily Care Processes: Evidence Behind Spontaneous Awakening Trials, S…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/manage-resident-RTI-facilitator-guide.docx
June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use
1
Management of a Resident With a Suspected Respiratory Tract Infection
Long-Term Care
Slide Title and Commentary
Slide Number and Slide
Management of a Resident With a Suspected Respiratory Tract Infection
Long-Term Care
SAY:
Welcome to this presentation, ti…
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psnet.ahrq.gov/node/33710/psn-pdf
May 01, 2011 - In Conversation with…Albert Wu, MD, MPH
May 1, 2011
In Conversation with…Albert Wu, MD, MPH. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
Editor's note: Albert Wu, MD, MPH, is Professor of Health Policy and Management at the Johns Hopkins
School of Public Health. A…
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psnet.ahrq.gov/node/49606/psn-pdf
August 01, 2010 - Weighing In on Surgical Safety
August 1, 2010
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/weighing-surgical-safety
Case Objectives
Identify the comorbidites associated with obesity that place patients at higher risk for surgical
complications.
Un…
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psnet.ahrq.gov/node/49550/psn-pdf
December 01, 2007 - Deaths Not Foretold: Are Unexpected Deaths Useful
Patient Safety Signals?
December 1, 2007
Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? PSNet
[internet]. 2007.
https://psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
The Case
…
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psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
April 09, 2014 - SPOTLIGHT CASE
The Hazards of Distraction: Ticking All the EHR Boxes
Citation Text:
Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
…
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening-2004
May 15, 2004 - Share to Facebook
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archived
Final Recommendation Statement
Lung Cancer: Screening, May 2004
May 15, 2004
Recommendations made by the USPSTF are independent of the U.S. government. The…
-
www.uspreventiveservicestaskforce.org/uspstf/recommendation/depression-screening-2002
May 07, 2002 - Share to Facebook
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Share to WhatsApp
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Print
archived
Final Recommendation Statement
Depression: Screening 2002
May 07, 2002
Recommendations made by the USPSTF are independent of the U.S. government. They shou…