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Total Results: 354 records

Showing results for "ambiguity".

  1. Errors and Near Misses: What Health Care Could Learn From Aviation | PSNet

    psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
    September 01, 2006 - identify weaknesses in systems and practices.( 12 ) One practical difficulty is resolving the inherent ambiguity

  2. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-331
    March 31, 2022 - March 2, 2022 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports, …

  3. In Conversation With… Michael Cohen, RPh, MS, ScD (hon) | PSNet

    psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
    October 24, 2021 - In Conversation With… Michael Cohen, RPh, MS, ScD (hon) October 1, 2018  Citation Text: In Conversation With… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50613/psn-pdf
    October 30, 2019 - In Conversation With… Neel Shah, MD, MPP October 30, 2019 In Conversation With… Neel Shah, MD, MPP. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-neel-shah-md-mpp Editor's note: Dr. Shah, MD, MPP, is an Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medi…

  5. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency | PSNet

    psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
    May 01, 2018 - SPOTLIGHT CASE Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency Citation Text: Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…

  6. All in the History | PSNet

    psnet.ahrq.gov/web-mm/all-history
    February 28, 2011 - SPOTLIGHT CASE All in the History Citation Text: Fee C. All in the History. 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 7 XML Endnot…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33867/psn-pdf
    October 01, 2018 - In Conversation With… Michael Cohen, RPh, MS, ScD (hon) October 1, 2018 In Conversation With… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0 Editor's note: Dr. Cohen is President of the Institute for Safe Medication Practice…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33752/psn-pdf
    August 01, 2013 - In Conversation With… J. Bryan Sexton, PhD, MA August 1, 2013 In Conversation With… J. Bryan Sexton, PhD, MA. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma Editor's note: J. Bryan Sexton, PhD, is associate professor and director of the Patient Safety Center for the D…

  9. Microsoft PowerPoint - Spotlight Case_Hindsight is 2020_SLIDES_FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_hindsight_is_2020_slides_final.pdf
    January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Hindsight is 2020_SLIDES_FINAL.pptx Spotlight Hindsight is 20/20: Thrombolytics for Alcohol Intoxication Source and Credits • This presentation is based on the April 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is avail…

  10. In Conversation With… J. Bryan Sexton, PhD, MA | PSNet

    psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
    February 26, 2025 - In Conversation With… J. Bryan Sexton, PhD, MA August 1, 2013  Citation Text: In Conversation With… J. Bryan Sexton, PhD, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citati…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867497/psn-pdf
    February 26, 2025 - Retained Surgical Items: Causation and Prevention February 26, 2025 Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention Background A retained surgical item (RSI) is a surgical patient safety pro…

  12. Syringe Swap During Regional Block: A Case of Medication Error and Recovery | PSNet

    psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
    July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery Citation Text: Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49415/psn-pdf
    September 01, 2003 - Intubation Mishap September 1, 2003 Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/intubation-mishap Case Objectives To understand and apply a structured method of human factors case analysis To describe the key components of effective teamwork To understand the imp…

  14. Safety I, Safety II, and the New Views of Safety | PSNet

    psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
    October 02, 2024 - Safety I, Safety II, and the New Views of Safety Citation Text: Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX E…

  15. Retained Surgical Items: Causation and Prevention | PSNet

    psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
    January 04, 2024 - Retained Surgical Items: Causation and Prevention Citation Text: Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX End…

  16. Spotlight Case Hindsight Is 2020 Slides Final Revised 05.03.2024 (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
    January 01, 2024 - Spotlight Hindsight is 20/20: Thrombolytics for Alcohol Intoxication Source and Credits • This presentation is based on the April 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Eric Signoff, MD, Noelle Boctor, MD, and David K. B…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867651/psn-pdf
    February 26, 2025 - Safety I, Safety II, and the New Views of Safety February 26, 2025 Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety Background and Context Safety I and Safety II (Safety I/II) are not safety method…

  18. Intubation Mishap | PSNet

    psnet.ahrq.gov/web-mm/intubation-mishap
    April 26, 2023 - SPOTLIGHT CASE Intubation Mishap Citation Text: Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/864867/psn-pdf
    April 10, 2024 - Hindsight is 20/20: Thrombolytics for Alcohol Intoxication April 10, 2024 Hindsight is 20/20: Thrombolytics for Alcohol Intoxication. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/hindsight-2020-thrombolytics-alcohol-intoxication Disclosure of Relevant Financial Relationships: As a provider accredited by th…

  20. Hindsight is 20/20: Thrombolytics for Alcohol Intoxication | PSNet

    psnet.ahrq.gov/web-mm/hindsight-2020-thrombolytics-alcohol-intoxication
    December 18, 2024 - SPOTLIGHT CASE Hindsight is 20/20: Thrombolytics for Alcohol Intoxication Citation Text: Hindsight is 20/20: Thrombolytics for Alcohol Intoxication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation …
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