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psnet.ahrq.gov/node/49434/psn-pdf
February 01, 2004 - Undiagnosed Vaginal Bleeding
February 1, 2004
Mandelblatt J. Undiagnosed Vaginal Bleeding . PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
The Case
The patient is a 34-year-old gravida 3, para 3 woman with a 2-year history of increasingly profuse vaginal
bleeding. Over the past…
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psnet.ahrq.gov/node/49703/psn-pdf
March 01, 2014 - After-Visit Confusion
March 1, 2014
Ventres W. After-Visit Confusion. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/after-visit-confusion
The Case
An otherwise healthy 18-year-old woman presented to an urgent care clinic with new bumps and white
spots near her tongue. The patient's mother accompanied her …
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T1-Talking_with_Residents_Final.pdf
October 01, 2016 - Nursing Home
Antimicrobial Stewardship Guide
Educate & Engage Residents, Family
Toolkit To Educate and Engage Residents and Family Members
Tool 1. Talking With Residents
These talking points are presented in Q&A format to encourage an open and respectful dialogue
between nurses or prescribing clinicians and res…
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T2-Talking_with_Residents_Family_Members_Final.docx
October 01, 2016 - Tool 2. Talking With Residents’ Family Members
These talking points are presented in Q&A format to encourage an open and respectful dialogue between nurses or prescribing clinicians and residents’ family members about antibiotics and the risks involved with taking antibiotics. The talking points are designed to: (1) ed…
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psnet.ahrq.gov/node/33611/psn-pdf
July 01, 2005 - In Conversation with…Christopher P. Landrigan, MD
April 1, 2005
In Conversation with…Christopher P. Landrigan, MD. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
Editor's Note: In October 2004, in what immediately became a landmark paper in patient safety, Dr.…
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www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/webinar05/mixedmethods.html
June 01, 2017 - Advanced Methods in Delivery System Research - Planning, Executing, Analyzing, and Reporting Research on Delivery System Improvement
Webinar #5: Mixed Methods (Slide Presentation)
This slide presentation was presented at a webinar on December 3, 2013.
Slide 1
Advanced Methods Webinars: Integrating Mixed…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/webinar05/mixed_methods.pptx
December 03, 2013 - Advanced Methods in Delivery System Research – Planning, Executing, Analyzing, and Reporting Research on Delivery System Improvement Webinar #1: Fuzzy Set Analysis
Advanced Methods Webinars:
Integrating Mixed Methods in Health Services and Delivery System Research
Presenters:
Benjamin Crabtree, PhD
Michael K. Magi…
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www.ahrq.gov/teamstepps-program/curriculum/intro/explain.html
July 01, 2023 - Section 2: Explanation and Value of the TeamSTEPPS Curriculum
This section contains explanations and illustrations to help you better understand and appreciate the structure and importance of the TeamSTEPPS curriculum and its key concepts. If you teach this content or want additional insights into how the mate…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-sops-riverside-handoffs-webcast-hansford.pdf
January 01, 2023 - Improving Hospital Handoffs Using AHRQ’s Surveys on Patient Safety Culture® Hospital Survey - Hansford and Murray
Assessing Patient Safety Culture to
Improve Hospital Handoffs
Ashley Hansford, BS, CPPS
Patient Safety Manager
Lauren Murray, MSN, RN, CMSRN
Director of Nursing, Med/Surg Unit
Riverside Health Sys…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/facapplycusp.docx
June 02, 2025 - SAY:
The “Apply CUSP” module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit introduces Just Culture principles, which emphasize shared accountability and attitudes toward risk. This module also summarizes the concepts and activities of the other six modules in the CUSP Toolkit.
Slide 1
SAY:
In th…
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psnet.ahrq.gov/node/33625/psn-pdf
January 01, 2006 - Aviation Safety Methods: Quickly Adopted but Questions
Remain
January 1, 2006
Thomas EJ. Aviation Safety Methods: Quickly Adopted but Questions Remain. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain
Perspective
On August 2, 2005, Air France flig…
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psnet.ahrq.gov/node/49731/psn-pdf
April 01, 2015 - Fire in the Hole!—An OR Fire
April 1, 2015
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/fire-hole-or-fire
The Case
A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection
for a biopsy-proven adenocarcinom…
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psnet.ahrq.gov/node/49694/psn-pdf
October 01, 2013 - Are You Mrs. A? An Issue of Identification Over
Telephone
October 1, 2013
Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
The Case
Mr. A was a 78-year-old man admitted with non-ST elevation…
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psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3
Citation Text:
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/workforce-executive-summary.pdf
October 01, 2016 - AHRQ New Models of Primary Care Workforce and Financing - Executive Summary
New Models of Primary Care
Workforce and Financing
Executive Summary
AHRQ New Models of Primary Care Workforce and
Financing
Executive Summary
Prepared for:
Agency for Healthcare Research and …
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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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psnet.ahrq.gov/node/33782/psn-pdf
March 01, 2015 - Where Does Risk-Adjusted Mortality Fit Into a Safety
Measurement Program?
March 1, 2015
Scott IA. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? PSNet [internet].
2015.
https://psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
Perspective
Much…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.272_slideshow.ppt
July 01, 2012 - Spotlight Case July 2008
Spotlight Case
Not-So-Therapeutic Tap
*
*
Source and Credits
This presentation is based on the July 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jeffrey H. Barsuk, MD, MS; Northwestern University Feinberg Scho…
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digital.ahrq.gov/sites/default/files/docs/page/2006ClancyKeyesYoung_051211comp.pdf
June 16, 2021 - Acknowledging Our Track Chairs
Acknowledging Our Track Chairs
Steve Simon, Harvard Medical School
Jack Starmer, Vanderbilt University
Atif Zafar, Indiana University
Marc Overhage, Regenstrief Institute
Mark Frisse, Vanderbilt University
Jan Walker, Partners Health Care and Cntr for Health IT Leadership
…
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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 …