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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - Failure to Latch
September 1, 2008
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/failure-latch
The Case
The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to
breastfeeding exclusively for 6 months. However, early br…
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psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - Medical Devices in the "Wild"
Citation Text:
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Format:
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - Acute Respiratory Arrest in Pregnancy
Citation Text:
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
October 01, 2011 - SPOTLIGHT CASE
Abdominal Aortic Aneurysm Screening
Citation Text:
Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/fire-hole-or-fire
August 03, 2017 - Fire in the Hole!—An OR Fire
Citation Text:
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/33645/psn-pdf
February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and
Umpires Have in Common?
February 1, 2007
Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? PSNet
[internet]. 2007.
https://psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
Perspectiv…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module2/putoolkit_module2_tools.docx
February 16, 2011 - Pressure Ulcer Prevention Toolkit
Pressure Ulcer Prevention Toolkit
Module 2 Tools
2A: Multidisciplinary Team
2B: Quality Improvement Process
2C: Current Process Analysis
2D: Assessing Pressure Ulcer Policies
2E: Assessing Screening for Pressure Ulcer Risk
2F: Assessing Pressure Ulcer Care Planning
2I: Action Plan
…
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psnet.ahrq.gov/node/49440/psn-pdf
March 01, 2004 - Autopsy Revelation
March 1, 2004
Shojania KG. Autopsy Revelation. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/autopsy-revelation
The Case
A 45-year-old male with development delay presented to the emergency department with acute abdominal
pain. His mother, who was his main caregiver, accompanied him. Th…
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psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - Spotlight
Spotlight
False Assumptions Result in a Missed
Pneumothorax after Bronchoscopy with
Transbronchial Biopsy
Source and Credits
• This presentation is based on the September 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by:…
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psnet.ahrq.gov/web-mm/urinary-retention-dilemma
March 01, 2013 - Urinary Retention Dilemma
Citation Text:
Joseph AC. Urinary Retention Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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www.ahrq.gov/research/findings/final-reports/ptflow/section5.html
July 01, 2018 - Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals
Section 5. Preparing to Launch
Previous Page Next Page
Table of Contents
Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals
Acknowledgments
Executive Summary
Section 1…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/rapid-response/rapid-response-fac-guide.html
July 01, 2023 - Rapid Response for Perinatal Safety: Facilitator Guide
AHRQ Safety Program for Perinatal Care
Slide 1: AHRQ Safety Program for Perinatal Care
Say:
The Rapid Response for Perinatal Safety bundle provides information establishing a unitwide approach, also referred to as a rapid response system, for respon…
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psnet.ahrq.gov/node/846770/psn-pdf
March 29, 2023 - Procedure Complications – Who is Responsible for
Follow up?
March 29, 2023
Chalupsky M, Wei H, Marquet E. Procedure Complications – Who is Responsible for Follow up? PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
The Case
A 74-year-old man with newly diagnose…
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/engaging-patients-in-treatment
January 01, 2023 - An official website of the Department of Health & Human Services
Search All AHRQ Sites
Careers
Contact Us
Español
FAQs
Email Updates
The Academy
Integrating Behavioral Health & Primary Care
Expand Navi…
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www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide3.html
February 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism
Chapter 3. Outline the Evidence and Identify Best Practices
Previous Page Next Page
Table of Contents
Preventing Hospital-Associated Venous Thromboembolism
Preface
Executive Summary
Chapter 1. The Framework for Improvement
Chapter 2. Anal…
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psnet.ahrq.gov/clinical-areas
March 24, 2025 - Clinical Areas
Scroll down to search or browse using Clinical Area if you would like to explore PSNet by the healthcare profession, such as the nurse care or medical specialty, featured in the resources.
Latest by Clinical Areas
In Conversation with Edwin Boudreaux about S…
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www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/measures/measure-3.html
November 01, 2017 - Established Child Health Care Quality Measures: AHRQ Quality Indicators
Child Health Care Quality Toolbox
The Child Health Toolbox contains concepts, tips, and tools for evaluating the quality of health care for children.
Contents
Pediatric Quality Indicators
Child-Specific Quality Indicators
Availa…
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www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/part3-nqs6.html
June 01, 2018 - Chartbook on Health Care for Blacks
Part 3: National Quality Strategy Priority—Healthy Living
Previous Page Next Page
Table of Contents
Chartbook on Health Care for Blacks
Health Care for Blacks
Acknowledgments
Part 1: Overviews of the Report and the Black Population
Part 2: Trends in Priori…
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-0-introduction.pdf
September 01, 2015 - Primary Care Practice Facilitation Curriculum Introduction
Primary Care
Practice Facilitation
Curriculum
Introduction
Agency for Healthcare Research and Quality
Advancing Excellence in Health Care www.ahrq.gov
Primary Care Practice Facilitation Curriculum
Introduction
Prepared for:
Agency…
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www.ahrq.gov/ncepcr/research-transform-primary-care/transform/cost/guide.html
October 01, 2015 - Estimating the Costs of Primary Care Transformation: A Practical Guide and Synthesis Report
A Practical Guide for Estimating the Costs of Primary Care Transformation
Previous Page Next Page
Table of Contents
Estimating the Costs of Primary Care Transformation: A Practical Guide and Synthesis Report …