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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/spread/spreadnotes.docx
June 02, 2025 - SAY:
The Spread module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit helps all or part of an organization share, tailor, and use the components of a process that have worked well at the unit level. The other CUSP Toolkit modules focus on quality improvement projects at the unit level, where culture i…
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psnet.ahrq.gov/node/49734/psn-pdf
May 01, 2015 - Departure From Central Line Ritual
May 1, 2015
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/departure-central-line-ritual
The Case
A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alco…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
May 01, 2015 - PowerPoint Presentation
Spotlight
Errors in Sepsis Management
This presentation is based on the May 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: David Shimabukuro, MD, University of California, San Francisco (UCSF)
Editor, AHRQ WebM&M: Rober…
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psnet.ahrq.gov/node/72693/psn-pdf
January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room
– Mixing Up the Ampules
January 29, 2021
Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
The Case
A…
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psnet.ahrq.gov/node/49607/psn-pdf
August 01, 2010 - Missed Patient Assignment: Is Anyone There?
August 1, 2010
Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
The Case
In one hospital, nurses' patient assignments were communicated by listing the…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.docx
May 01, 2017 - AHRQ Safety Program for Perinatal Care
Monitoring for Perinatal Safety: Electronic Fetal Monitoring
Monitoring for Perinatal Safety—Electronic Fetal Monitoring
SAY:
The Monitoring for Perinatal Safety bundle provides information on the use of electronic fetal monitoring (EFM). This bundle offers an approach to the us…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-fac-guide.html
July 01, 2023 - Monitoring for Perinatal Safety: Electronic Fetal Monitoring: Facilitator Guide
AHRQ Safety Program for Perinatal Care
Slide 1: Monitoring for Perinatal Safety: Electronic Fetal Monitoring
Say:
The Monitoring for Perinatal Safety bundle provides information on the use of electronic fetal monitoring (EFM…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_cord-prolapse.docx
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Sample Scenario for Umbilical Cord Prolapse In Situ Simulation
AHRQ Safety Program for Perinatal Care
Sample Scenario for Umbilical Cord Prolapse In Situ Simulation
Sample Scenario for Umbilical Cord Prolapse In Situ Simulation
Purpose of the tool: The Umbilical Cord Prolapse …
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/simulation-cord-prolapse.html
July 01, 2023 - Sample Scenario for Umbilical Cord Prolapse In Situ Simulation
AHRQ Safety Program for Perinatal Care
Purpose of the tool: The Umbilical Cord Prolapse In Situ Simulation tool provides a sample scenario for labor and delivery (L&D) staff to practice teamwork, communication, and technical skills in…
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www.ahrq.gov/sites/default/files/wysiwyg/CHIPRA_15-P002-EF-revised.pdf
March 01, 2015 - Measures: Family Experiences With Care Coordination Measure Set (FECC)
Measures: Family Experiences with Care
Coordination Measure Set (FECC)
Measure Developer: Center of Excellence on Quality of Care Measures for Children with
Complex Needs (COE4CCN)
Numerator Denominator Exclusions Data Source(s)
The FECC Surv…
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psnet.ahrq.gov/node/49736/psn-pdf
June 01, 2015 - Inflicting Confusion
June 1, 2015
Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/inflicting-confusion
The Case
A 26-year-old man with recently diagnosed Crohn disease presented to the emergency department with
acute-onset abdominal pain, nausea, vomiting, an…
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psnet.ahrq.gov/node/49459/psn-pdf
September 01, 2004 - Caution, Interrupted
September 1, 2004
Wears RL. Caution, Interrupted. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/caution-interrupted
The Case
A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and
neutropenia presented to the emergency department (ED) with …
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/challenging-patient-behaviors-and-concerns
January 01, 2021 - 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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hcup-us.ahrq.gov/reports/Trends_NeonatalAbstinenceSyndrome_Births_UnitedStates.pdf
January 18, 2019 - Trends in Neonatal Abstinence Syndrome Births in the United States
NAS Births in the U.S. 1 Updated: 01/18/2019
Estimates for 2016 include data from the following: Alaska, Arizona, Arkansas, California, Colorado, Connecticut,
Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas…
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psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
April 28, 2021 - Procedural Mishap: Learning Curve?
Citation Text:
Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML En…
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psnet.ahrq.gov/web-mm/dangerous-dapsone
January 10, 2011 - Dangerous Dapsone
Citation Text:
Bookwalter T. Dangerous Dapsone. 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/49604/psn-pdf
June 01, 2010 - Tacit Handover, Overt Mishap
June 1, 2010
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
The Case
A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3
years earlier to treat an abdo…
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psnet.ahrq.gov/node/49739/psn-pdf
August 21, 2015 - Breathe Easy: Safe Tracheostomy Management
August 21, 2015
Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
The Case
A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumo…
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www.ahrq.gov/research/findings/final-reports/stpra/stpra3.html
April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Chapter 3. Risk-Informed Interventions
Previous Page Next Page
Table of Contents
Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Executive Summary
Chapter 1. Introduction
Chapt…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/podcasts/Tackling_Low_Health_Literacy_Among_PCP_2012_05_01_Transcript.pdf
January 01, 2012 - Tackling Low Health Literacy Among Primary Care Patients: A Model from Missouri
Tackling Low Health Literacy Among Primary Care Patients: A Model from Missouri
May 2012 Podcast
Speaker
Stan Hudson, Associate Director, Center for Health Policy, University of Missouri; Chairman, Health Literacy
Education …