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psnet.ahrq.gov/node/33848/psn-pdf
December 01, 2017 - The Evolution of Patient Safety in Surgery
December 1, 2017
Wachter R. The Evolution of Patient Safety in Surgery. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
Perspective
In 1979, 20 years before the Institute of Medicine's To Err Is Human report (1) catalyzed the cr…
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/high-reliability-journey-slides.pptx
September 26, 2023 - VHA's Journey to High Reliability: Advancing Toward Zero Harm and Becoming a Learning Health System
September 26, 2023
Pre-Decisional Deliberative Document
Internal VA Use Only
Advancing Toward Zero Harm and
Becoming a Learning Health System
Gerard R. Cox, MD, MHA
Assistant Under Secretary for Health for Quality & …
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psnet.ahrq.gov/node/33631/psn-pdf
April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to
Promote a Culture of Safety
April 1, 2006
Alldredge BK, Koda-Kimble MA. Count and Be Counted: Preparing Future Pharmacists to Promote a
Culture of Safety. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacis…
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psnet.ahrq.gov/node/49488/psn-pdf
August 21, 2005 - PCA Overdose
August 21, 2005
Doyle JD. PCA Overdose. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pca-overdose
The Case
A 49-year-old woman underwent an uneventful total abdominal hysterectomy bilateral salpingo-
oophorectomy. Postoperatively, the patient complained of severe pain and received intravenou…
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psnet.ahrq.gov/node/49716/psn-pdf
August 21, 2014 - Benefits vs. Risks of Intraosseous Vascular Access
August 21, 2014
Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
The Case
A 72-year-old woman with a history of asthma, congestive heart…
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psnet.ahrq.gov/node/49404/psn-pdf
June 01, 2003 - Not a Miscarriage
June 1, 2003
Learman LA. Not a Miscarriage. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/not-miscarriage
The Case
A 32-year-old woman, gravida 3, para 1, with a history of Type 2 diabetes mellitus on metformin, presented
at 7 and 2/7 weeks by last menstrual period (LMP). The patient rep…
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psnet.ahrq.gov/node/49578/psn-pdf
January 01, 2009 - Hospital Admission Due to High-Dose Methotrexate Drug
Interaction
January 1, 2009
Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet
[internet]. 2009.
https://psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
The Case
A 40-year-old wo…
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psnet.ahrq.gov/node/49701/psn-pdf
February 01, 2014 - An Easily Forgotten Tube
February 1, 2014
Ousey K. An Easily Forgotten Tube. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/easily-forgotten-tube
The Case
A 45-year-old man was admitted to the intensive care unit (ICU) for acute liver failure secondary to alcohol
abuse. His illness was complicated by acute…
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psnet.ahrq.gov/node/49781/psn-pdf
January 01, 2017 - Hazards of Loading Doses
January 1, 2017
Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hazards-loading-doses
The Case
A 40-year-old woman was recently discharged after a prolonged hospitalization for seizures and a cardiac
arrest. Two days after discharg…
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psnet.ahrq.gov/node/49842/psn-pdf
September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric
Emergency Equipment
September 1, 2018
Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet
[internet]. 2018.
https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
The Case
As part of…
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psnet.ahrq.gov/node/60548/psn-pdf
May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD
May 28, 2020
In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd
Editor’s note: Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at
the Food…
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psnet.ahrq.gov/node/33615/psn-pdf
June 01, 2005 - In Conversation with…Peter J. Pronovost, MD, PhD
June 1, 2005
In Conversation with…Peter J. Pronovost, MD, PhD. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
Editor's Note: Peter J. Pronovost, MD, PhD, is Medical Director of the Johns Hopkins Center for
Innova…
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psnet.ahrq.gov/node/49590/psn-pdf
January 01, 2010 - Is the Admission Drug Dose Too Low?
August 1, 2009
Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
The Case
A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to
the hospit…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-235-pharma-nonpharm-ptsd-update-appendix-g-1.xlsx
May 29, 2025 - G-1. Additions to ROB Template
Table G-2. Additions to risk of bias template
Rater Author, Year Selection Bias Domain: Randomization Adequate? Selection Bias Domain: Allocation Concealment Adequate? Selection Bias Domain: Groups Similar at Baseline? Selection Bias Domain: ITT Analysis? Performance Bias Domain: Care P…
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digital.ahrq.gov/ahrq-funded-projects/parentlink-better-and-safer-emergency-care-children
January 01, 2023 - ParentLink: Better and Safer Emergency Care for Children
Project Final Report ( PDF , 84.92 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHR…
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www.ahrq.gov/ncepcr/communities/pbrn/registry/index.html?page=0
Practice-based Research Networks Registry
Results Displaying 1 - 50 of 204 PBRNs
Pagination
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A. T. Still University, School of Osteopathic Medicine in Arizona PBRN Acronym: ATSU SOMA PBRN Network Type: Mixed…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/subglottic-slides.pptx
January 01, 2017 - Presentation: Program Overview
AHRQ Safety Program for Mechanically Ventilated Patients
Benefits of
Subglottic Secretion Drainage
Endotracheal Tubes
AHRQ Pub. No. 16(17)-0018-45-EF
January 2017
SSD-ETT Benefits ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
Learning Objectives
After this session, y…
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-module-2-slides.pptx
June 02, 2025 - TeamSTEPPS Team Leadership Module 2
Team Leadership
Module 2
1
Understanding Teams and Team Structure
2
Objectives: Team Structure
Team Leadership
Understand the benefits of teamwork and clear team structure.
Define a “team.”
Identify the roles of patients and family caregivers within the care team.
Desc…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/program-part2-slides.pptx
November 01, 2019 - Acute Care ASP Development
Antibiotic Stewardship Program Development: Part 2
Acute Care
AHRQ Safety Program for Improving
Antibiotic Use
AHRQ Pub. No. 17(20)-0028-EF
November 2019
ASP Development – Part 2
AHRQ Safety Program for Improving Antibiotic Use – Acute Care
1
Objectives
By the end of this module, parti…
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digital.ahrq.gov/ahrq-funded-projects/incorporating-patient-reported-outcomes-shared-decision-making-patients
August 31, 2024 - Incorporating Patient-Reported Outcomes into Shared Decision Making with Patients with Osteoarthritis of the Knee
Project Final Report ( PDF , 238.8 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its con…