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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. 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, …
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. 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…
  9. 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…
  10. 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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. 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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. 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…
  17. 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…
  18. 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…
  19. 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…
  20. 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…