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  1. Empty Handoff | PSNet

    psnet.ahrq.gov/web-mm/empty-handoff
    August 01, 2017 - Empty Handoff Citation Text: Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…

  2. Clostridium Difficile Relapse Secondary to Medication Access Issue | PSNet

    psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
    October 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue Citation Text: Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Cit…

  3. CVC Placement: Speak Now or Do Not Use the Line | PSNet

    psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
    November 01, 2003 - CVC Placement: Speak Now or Do Not Use the Line Citation Text: Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar …

  4. Final Progress Report: Diagnostic Error in Medicine Conference 2020-2022 (pdf file)

    www.ahrq.gov/sites/default/files/2025-04/castro-report.pdf
    January 01, 2025 - Final Progress Report: Diagnostic Error in Medicine Conference 2020-2022 Title Page – Final Progress Report Title: Diagnostic Error in Medicine Conference 2020-2022 Principal Investigator: Gerry Castro, PhD, MPH Team Members: 2022 Conference Chairs, Co-chairs and Planning Commitee members Andrew Olson…

  5. Carman-notes-151021 copy-Teresa (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/carman-presentation.pdf
    May 29, 2025 - Carman-notes-151021 copy-Teresa We got invited to submit a publication to Health Affairs in 2013 that really asked us to think, “How do we think about patient and   family engagement? How can  we think about what are the major issues in  this area?” We've been   thinking about this concept for a long time, …

  6. Continuity Errors in Resident Clinic | PSNet

    psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
    October 02, 2019 - Continuity Errors in Resident Clinic Citation Text: Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …

  7. Research White Paper: Standardized Library of Depression Outcome Measures (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/standardized-library-depression-white-paper.pdf
    May 01, 2020 - Research White Paper: Standardized Library of Depression Outcome Measures Research White Paper Standardized Library of Depression Outcome Measures Research White Paper Standardized Library of Depression Outcome Measures Prepared for: Agency for Healthcare Research and Qual…

  8. Too Tight Control | PSNet

    psnet.ahrq.gov/web-mm/too-tight-control
    March 20, 2013 - SPOTLIGHT CASE Too Tight Control Citation Text: Rubin HR, Fajtova VT. Too Tight Control. 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…

  9. Chartbook #2: Racial and Ethnic Differences in Health 1996

    meps.ahrq.gov/data_files/publications/cb2/cb2.shtml
    February 01, 1999 - Chartbook #2: Racial and Ethnic Differences in Health 1996   Skip to main content An official website of the Department of Health & Human Services More Back Search ah…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49779/psn-pdf
    January 01, 2017 - The Empty Bag December 1, 2016 Vincent C. The Empty Bag. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/empty-bag The Case A 90-year-old woman with end-stage dementia was admitted to an acute care hospital for treatment of a hip fracture after a fall at a nursing home. During the hospitalization, her kidne…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74251/psn-pdf
    January 26, 2022 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest January 26, 2022 Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. 2022. https…

  12. Psn-Pdf (pdf file)

    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 …

  13. Psn-Pdf (pdf file)

    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 …

  14. Psn-Pdf (pdf file)

    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…

  15. Psn-Pdf (pdf file)

    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…

  16. Psn-Pdf (pdf file)

    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…

  17. Psn-Pdf (pdf file)

    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…

  18. Psn-Pdf (pdf file)

    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…

  19. Psn-Pdf (pdf file)

    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…

  20. Psn-Pdf (pdf file)

    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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