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psnet.ahrq.gov/node/49436/psn-pdf
February 26, 2004 - Transfusion "Slip"
February 1, 2004
Kaplan HS. Transfusion "Slip". PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/transfusion-slip
The Case
A married couple, Mr. and Mrs. M, was brought to the emergency department (ED) of a Level 1 trauma
center after a half-ton truck that had skidded out of control struck…
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psnet.ahrq.gov/node/73999/psn-pdf
October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in
the Operating Room
October 27, 2021
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
…
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psnet.ahrq.gov/node/49459/psn-pdf
September 01, 2004 - Caution, Interrupted
September 1, 2004
Wears RL. Caution, Interrupted. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/caution-interrupted
The Case
A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and
neutropenia presented to the emergency department (ED) with …
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psnet.ahrq.gov/node/49401/psn-pdf
May 01, 2003 - Suicidal Man With Gun
May 1, 2003
Simon RI. Suicidal Man With Gun. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/suicidal-man-gun
The Case
The patient is a 36-year-old man who came to a psychiatry clinic for outpatient evaluation of severe
depression that had persisted for nearly 2 years. On initial inter…
-
psnet.ahrq.gov/node/72587/psn-pdf
December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric
Patients at Risk of Physiologic Instability
December 23, 2020
Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at
Risk of Physiologic Instability. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm…
-
psnet.ahrq.gov/node/49423/psn-pdf
November 01, 2003 - The Missing Suction Tip
November 1, 2003
Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/missing-suction-tip
Case Objectives
Identify the risk factors for retained foreign bodies.
Understand methods used to prevent and identify retained foreign bodies.
Apprecia…
-
psnet.ahrq.gov/node/49691/psn-pdf
September 01, 2013 - DRESSed for Failure
September 1, 2013
Abramson EL, Kaushal R. DRESSed for Failure. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/dressed-failure
The Case
A 60-year-old woman who uses a wheelchair presented to the emergency department (ED) with right hand
cellulitis and an uncomplicated urinary tract infec…
-
psnet.ahrq.gov/node/49711/psn-pdf
June 01, 2014 - Wandering Off the Floors: Safety and Security Risks of
Patient Wandering
June 1, 2014
Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
Case Objectives
Define patie…
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psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
September 01, 2005 - Benefits vs. Risks of Intraosseous Vascular Access
Citation Text:
Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Citation
Format:
Go…
-
psnet.ahrq.gov/node/33699/psn-pdf
August 01, 2010 - Operationalizing Patient Safety at Academic Medical
Centers
August 1, 2010
Chakraborti C, Kahn MJ, Krane K. Operationalizing Patient Safety at Academic Medical Centers. PSNet
[internet]. 2010.
https://psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
Perspective
Academic medical…
-
psnet.ahrq.gov/node/49739/psn-pdf
August 21, 2015 - Breathe Easy: Safe Tracheostomy Management
August 21, 2015
Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
The Case
A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumo…
-
psnet.ahrq.gov/node/49674/psn-pdf
December 01, 2012 - Preventing PICC Complications: Whose Line Is It?
December 1, 2012
Moureau N. Preventing PICC Complications: Whose Line Is It? PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
The Case
A 55-year-old woman with myasthenia gravis, hypertension, and hypothyroidism prese…
-
psnet.ahrq.gov/node/49625/psn-pdf
May 01, 2011 - Pocket Syringe Swap
May 1, 2011
Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/pocket-syringe-swap
The Case
A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for
postoperative pain management. Surgery proceeded uneventfully under…
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cdsic.ahrq.gov/sites/default/files/2024-12/OY2_Final%20IAS%20Workgroup%20Charter.pdf
January 01, 2024 - Implementation, Adoption, and Scaling Workgroup: Charter – Option Year 2
Implementation, Adoption, and
Scaling Workgroup: Charter –
Option Year 2
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
www.ahrq.gov
Contract No: 75Q80120D00018
Prepared by:
NORC at the…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
August 01, 2022 - Module 5: Response and Disclosure
AHRQ Communication and Optimal Resolution Toolkit
Facilitator Notes
Say:
In Module 5 of the CANDOR Toolkit, we will discuss the Response and Disclosure component of the CANDOR process.
Slide 1
Say:
The goal of this module is to:
Define…
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www.ahrq.gov/sites/default/files/wysiwyg/chsp/bundled-payments_0.pdf
January 01, 2019 - Health System Participation in Medicare Bundled Payment Models, 2016
1
Comparative
Health System
Performance
Initiative
Health System Participation
in Medicare Bundled
Payment Models, 2016
Data Highlight, No. 6 January 2019
Hospital participation in Medicare bundled payment models,
by system membership
Sy…
-
www.ahrq.gov/sites/default/files/wysiwyg/chsp/ma-plans.pdf
March 01, 2019 - Provider-Offered Medicare Advantage Plans Among U.S. Health Systems, 2016
1
Comparative
Health System
Performance
Initiative
Provider-Offered Medicare
Advantage Plans Among U.S.
Health Systems, 2016
Data Highlight, No. 7 March 2019
Systems offering a Medicare Advantage (MA) plan
About 12% of systems offer …
-
www.ahrq.gov/sites/default/files/wysiwyg/chsp/insurance-products.pdf
January 01, 2019 - Provider-Offered Insurance Products Among U.S. Health Systems, 2016
1
Comparative
Health System
Performance
Initiative
Provider-Offered Insurance
Products Among U.S. Health
Systems, 2016
Data Highlight, No. 5 January 2019
Systems offering an insurance product
Nearly 4 in 10 systems offer an insurance produ…
-
digital.ahrq.gov/sites/default/files/docs/medication-without-harm-qas-07242024.pdf
July 24, 2024 - AHRQ National Webinar on Medication Without Harm – How Digital Healthcare Tools Can Support Providers and Improve Patient Safety - Q&As
…
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digital.ahrq.gov/ahrq-funded-projects/improving-healthcare-quality-user-centric-patient-portals
January 01, 2023 - Improving Healthcare Quality with User-Centric Patient Portals
Project Final Report ( PDF , 290.12 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…