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  1. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.113_slideshow.ppt
    January 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case January 2006 An Ounce of Prevention Source and Credits This presentation is based on the Jan. 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Nils Kucher, MD; University Ho…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49864/psn-pdf
    June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout June 1, 2019 Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…
  3. psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
    January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx Spotlight Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the ful…
  4. psnet.ahrq.gov/web-mm/ounce-prevention
    February 17, 2011 - SPOTLIGHT CASE An Ounce of Prevention Citation Text: Kucher N. An Ounce of Prevention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49608/psn-pdf
    August 01, 2010 - Emergent Triage Miss August 1, 2010 Travers D. Emergent Triage Miss. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/emergent-triage-miss The Case A 42-year-old woman presented to a busy urban emergency department (ED) and approached the triage nurse. The patient told the triage nurse that she had "3 days o…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33654/psn-pdf
    August 01, 2007 - In Conversation with...James L. Reinertsen, MD August 1, 2007 In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md Editor's Note: James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting firm …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33707/psn-pdf
    February 01, 2011 - The University of Texas System Clinical Safety and Effectiveness Course February 1, 2011 Thomas EJ, Patterson JE, Martin S, et al. The University of Texas System Clinical Safety and Effectiveness Course. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiv…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49543/psn-pdf
    September 01, 2007 - Medication Reconciliation: Whose Job Is It? September 1, 2007 Poon EG. Medication Reconciliation: Whose Job Is It? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it Case Objectives Appreciate the prevalence and impact of medication discrepancies at times of transition in …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49606/psn-pdf
    August 01, 2010 - Weighing In on Surgical Safety August 1, 2010 Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/weighing-surgical-safety Case Objectives Identify the comorbidites associated with obesity that place patients at higher risk for surgical complications. Un…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49857/psn-pdf
    March 01, 2019 - Duplicate Insulin Order March 1, 2019 Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/duplicate-insulin-order The Case A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency department (ED) for complaints of letharg…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842923/psn-pdf
    February 01, 2023 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. February 1, 2023 Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. PSNet [internet]. …
  12. psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
    August 20, 2018 - Buprenorphine and the Medically Ill Patient Citation Text: McCance-Katz EF. Buprenorphine and the Medically Ill Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX E…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49760/psn-pdf
    May 01, 2016 - Mismanagement of Delirium May 1, 2016 Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/mismanagement-delirium The Case An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although fitted with a cast at a regional ho…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861881/psn-pdf
    January 31, 2024 - In Conversation with...Richard Ricciardi about Office- Based Patient Safety January 31, 2024 Ricciardi R, Lee M, Mossburg S. In Conversation with..Richard Ricciardi about Office-Based Patient Safety. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-pa…
  15. digital.ahrq.gov/sites/default/files/docs/HealthITandUnderservedPopulations.pdf
    September 17, 2010 - National Web-Based Teleconference on Health IT and Underserved Populations: Health IT Adoption in Rural Clinical Settings National Web-Based Teleconference on Health IT and Underserved Populations Health IT Adoption in Rural Clinical Settings August 27, 2010 Moderator: Angela Lavanderos A…
  16. psnet.ahrq.gov/web-mm/breakage-picc-line
    June 21, 2023 - SPOTLIGHT CASE Breakage of a PICC Line Citation Text: Dimov V. Breakage of a PICC Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …
  17. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/manage-resident-RTI-facilitator-guide.docx
    June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use 1 Management of a Resident With a Suspected Respiratory Tract Infection Long-Term Care Slide Title and Commentary Slide Number and Slide Management of a Resident With a Suspected Respiratory Tract Infection Long-Term Care SAY: Welcome to this presentation, ti…
  18. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-patient-safety-facilitator-guide.docx
    June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use 1 Improving Antibiotic Use Is a Patient Safety Issue Long-Term Care Slide Title and Commentary Slide Number and Slide Improving Antibiotic Use Is a Patient Safety Issue Long-Term Care SAY: Welcome to this presentation titled “Improving Antibiotic Use Is a Patie…
  19. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
    June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use 1 Changing the System To Improve Patient Safety Long-Term Care Slide Title and Commentary Slide Number and Slide Changing the System To Improve Patient Safety SAY: Hello, and welcome to this presentation: “Changing the System To Improve Patient Safety.” Sl…
  20. www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-3-readiness-form.pdf
    August 01, 2005 - Is Your Organization Ready for TeamSTEPPS™? Is Your Organization Ready for TeamSTEPPS™? Answering these questions can help your institution understand its level of readiness to initiate the TeamSTEPPS program. You may find it helpful to have a colleague review your responses or to answer the questions with a large…