-
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…
-
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…
-
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…
-
psnet.ahrq.gov/node/49839/psn-pdf
August 01, 2018 - Mixup Beyond the Medication Label
August 1, 2018
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
The Case
An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another
hospi…
-
psnet.ahrq.gov/node/49697/psn-pdf
December 01, 2013 - Check the Anesthesia Machine
December 1, 2013
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/check-anesthesia-machine
The Case
A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension,
diabetes, sleep apnea…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.230_slideshow.ppt
December 01, 2010 - Spotlight Case July 2008
Spotlight Case
The Forgotten Turn
*
*
Source and Credits
This presentation is based on the December 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Susan Barbour, RN, FNP, University of California San Francisco …
-
psnet.ahrq.gov/node/49830/psn-pdf
May 01, 2018 - Suicide Risk in the Hospital
May 1, 2018
Mills PD. Suicide Risk in the Hospital. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/suicide-risk-hospital
The Case
A 37-year-old woman with a past medical history of depression, anxiety, and posttraumatic stress disorder
presented to the emergency department (ED)…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.362_slideshow.ppt
December 01, 2015 - PowerPoint Presentation
Spotlight
Harm From Alarm Fatigue
This presentation is based on the December 2015
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Michele M. Pelter, RN, PhD, and Barbara J. Drew, RN, PhD, University of California, San …
-
psnet.ahrq.gov/node/72737/psn-pdf
February 09, 2021 - Geisinger’s Outpatient Addiction Medicine Specialty
Program Uses Data-Driven Decision Making and MAT to
Reduce Mortality Rates
February 9, 2021
https://psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-
driven-decision
Summary
The team at Geisinger sought to develop a…
-
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…
-
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…
-
www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreensum.html
April 01, 2018 - Health Care Systems for Tracking Colorectal Cancer Screening Tests
Executive Summary
Previous Page Next Page
Table of Contents
Health Care Systems for Tracking Colorectal Cancer Screening Tests
Executive Summary
1. Introduction
2. Description of the Intervention
2. Description of the Interve…
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/manage-resident-RTI-slides.pptx
June 01, 2021 - PowerPoint Presentation
Management of a Resident With a Suspected Respiratory Tract Infection
Long-Term Care
AHRQ Safety Program for Improving Antibiotic Use
AHRQ Pub. No. 17(21)-0029
June 2021
Management RTI
1
Objectives
Review testing and empiric treatment options for pneumonia
Discuss opportunities for de-escal…
-
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…
-
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…
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/162-example-completed-learning-defects-tool.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
Learning From Defects Tool - Example
ICU & Non-ICU
Problem statement: Healthcare organizations can increase the extent to which they learn from defects. We define this learning as reducing the probability that future patients will be harmed.
What is a defect? A defect is any cli…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
December 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case December 2007
Elopement
Source and Credits
This presentation is based on the December 2007 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Debra Gerardi, RN, MPH, JD
Creighton University School of Law
Ed…
-
psnet.ahrq.gov/primer/missed-nursing-care
September 15, 2024 - Missed Nursing Care
Citation Text:
Missed Nursing Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
-
integrationacademy.ahrq.gov/sites/default/files/2020-12/Grantee%20Profile%20Virginia.pdf
January 01, 2020 - EvidenceNOW Managing Unhealthy Alcohol Use: Practice Facilitation to Promote Evidence-based Screening and Management of Unhealthy Alcohol Use in Primary Care
Virginia
Program Name:
Practice Facilitation to Promote
Evidence-based Screening and
Management of Unhealthy Alcohol
Use in Primary Care
Lead Organization:…
-
psnet.ahrq.gov/node/33579/psn-pdf
September 15, 2024 - Systems Approach
September 15, 2024
Systems Approach. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/systems-approach
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in …