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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…
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psnet.ahrq.gov/node/846768/psn-pdf
March 29, 2023 - Endotracheal Tube Fallout in a Patient with Severe
Obesity During Eye Surgery.
March 29, 2023
Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
The Ca…
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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…
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www.ahrq.gov/sites/default/files/2025-03/smith2-report.pdf
January 01, 2025 - Final Progress Report: A Study of Narrative as the Cognitive Process Underlying Diagnostic Reasoning
A Study of Narrative as the Cognitive Process Underlying Diagnostic Reasoning
PI: Curtis Scott Smith, MD
Team: Chris Francovich, EdD
Magdalena Morris, RN, MSN
Andrew Turner, PhD
Bruce Robbins, PhD
Lynne Robins, …
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psnet.ahrq.gov/node/33663/psn-pdf
September 15, 2008 - Implementing a Patient Safety Program at a Large
National Health System
January 1, 2008
Hauck LD, Jacob J. Implementing a Patient Safety Program at a Large National Health System. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
Perspectiv…
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psnet.ahrq.gov/node/33841/psn-pdf
September 01, 2017 - In Conversation With… Andrew Gettinger, MD
September 1, 2017
In Conversation With… Andrew Gettinger, MD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
Editor's note: Dr. Gettinger is the Chief Medical Information Officer and the Executive Director of the
Office of Cli…
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psnet.ahrq.gov/node/49798/psn-pdf
July 01, 2017 - Pseudo-obstruction But a Real Perforation
July 1, 2017
Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
Case Objectives
Recognize acute colonic pseudo-obstruction and implement a medical management plan.
Ide…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-event-reporting-revised.docx
April 01, 2022 - CLABSI Event Reporting Tool
CAUTI Event Report Tool: Data for Event Analysis
This event report tool is designed to be used as a guide through the initial investigation for a defect analysis where the primary goal is to learn what happened and what factors may have contributed to the catheter-associated urinary trac…
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www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6g.html
June 01, 2014 - Care Coordination Measures Atlas Update
Chapter 6. Measure Maps and Profiles (continued, 8)
Previous Page Next Page
Table of Contents
Care Coordination Measures Atlas Update
Chapter 1: Background
Chapter 2. What is Care Coordination?
Chapter 3. Care Coordination Measurement Framework
Chapter…
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www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6e.html
June 01, 2014 - Care Coordination Measures Atlas Update
Chapter 6. Measure Maps and Profiles (continued, 6)
Previous Page Next Page
Table of Contents
Care Coordination Measures Atlas Update
Chapter 1: Background
Chapter 2. What is Care Coordination?
Chapter 3. Care Coordination Measurement Framework
Chapter…
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psnet.ahrq.gov/node/49799/psn-pdf
July 01, 2017 - Delayed Recognition of a Positive Blood Culture
July 1, 2017
Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
The Case
A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress…
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psnet.ahrq.gov/node/33865/psn-pdf
September 01, 2018 - In Conversation With… Rebecca Lawton, PhD
September 1, 2018
In Conversation With… Rebecca Lawton, PhD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
Editor's note: Rebecca Lawton, a Professor in the Psychology of Healthcare at the University of Leeds, is
a health psycho…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-icu-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Early Mobility in the Intensive Care Unit
SAY:
In this slide set, we will look at the benefits, safety, feasibility, and sustainability of early mobility. Many hospitals and intensive care units or IC…
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psnet.ahrq.gov/node/33704/psn-pdf
December 01, 2010 - In Conversation with...Geri Amori, PhD
December 1, 2010
In Conversation with..Geri Amori, PhD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
Editor's note: Geri Amori, PhD, is Vice President for the Education Center at The Risk Management and
Patient Safety Institute, a…
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psnet.ahrq.gov/node/49450/psn-pdf
June 01, 2004 - The Wrong Shot: Error Disclosure
June 1, 2004
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
Case Objectives
Describe the rationale for disclosing harmful errors to patients.
Describe the specific information that patie…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-indications-notes.docx
April 01, 2022 - Indwelling Urinary Catheter Indications Facilitator Notes
CAUTI Module:
Indwelling Urinary Catheter Indications
Facilitator Guide
Slide Number and Image
This module, titled “Indwelling Urinary Catheter Indications” is part of the Agency for Healthcare Research and Quality’s Safety Program for Intensive Care Uni…
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www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/mod1.html
February 01, 2023 - Preventing CAUTI in the ICU Setting: Facilitator’s Guide
Module 1: Overview
Previous Page Next Page
Table of Contents
Preventing CAUTI in the ICU Setting: Facilitator’s Guide
Introduction
Module 1: Overview
Module 2: Urinary Catheter Maintenance
Module 3: Conversations Around Device Necessit…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
September 01, 2014 - PowerPoint Presentation
Spotlight
A Lot of Pain (Medications)
1
This presentation is based on the September 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Shoshana J. Herzig, MD, MPH, Division of General Medicine, Beth Israel Deaconess Medic…
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www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6x.html
June 01, 2014 - Care Coordination Measures Atlas Update
Chapter 6. Measure Maps and Profiles (continued, 25)
Previous Page Next Page
Table of Contents
Care Coordination Measures Atlas Update
Chapter 1: Background
Chapter 2. What is Care Coordination?
Chapter 3. Care Coordination Measurement Framework
Chapte…
-
www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6w.html
June 01, 2014 - Care Coordination Measures Atlas Update
Chapter 6. Measure Maps and Profiles (continued, 24)
Previous Page Next Page
Table of Contents
Care Coordination Measures Atlas Update
Chapter 1: Background
Chapter 2. What is Care Coordination?
Chapter 3. Care Coordination Measurement Framework
Chapte…