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Showing results for "analyzing".

2421. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
      October 01, 2010 - Spotlight Case July 2008 Spotlight Case October 2010 Dangerous Dialysis * * Source and Credits This presentation is based on the October 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jean L. Holley, MD, University of Illinois, Urbana-…

2422. Rapid Response Teams: Lessons from the Early Experience | PSNet
      psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
      November 01, 2005 - Developing strategies to prevent in hospital cardiac arrest: analyzing responses of physicians and nurses

2423. In Conversation With...Donald A. Norman, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
      November 01, 2006 - In Conversation With...Donald A. Norman, PhD November 1, 2006  Also Read an Essay Citation Text: In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006.In Conversation With...Donald A. Norman, PhD. PSNet [internet]. Rockville (MD): Agency for Healthca…

2424. Electrocardiogram Results: ***READ ME*** | PSNet
      psnet.ahrq.gov/web-mm/electrocardiogram-results-read-me
      May 01, 2019 - Electrocardiogram Results: ***READ ME*** Citation Text: Alpert JS. Electrocardiogram Results: ***READ ME***. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…

2425. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49587/psn-pdf
      May 01, 2009 - Missing Trauma May 1, 2009 Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/missing-trauma The Case A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a few minutes later by a customer, who immediately called 911. On arrival, para…

2426. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49623/psn-pdf
      March 01, 2011 - Are We Pushing Graduate Nurses Too Fast? March 1, 2011 Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast The Case A middle-aged man was admitted to the surgical intensive care unit (SICU) following a complex surgical…

2427. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49389/psn-pdf
      February 01, 2003 - Procedural Mishap: Learning Curve? February 1, 2003 Gibbs VC, Leape L. Procedural Mishap: Learning Curve? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve The Case A 28-year-old multiparous obese female presented for laparoscopic tubal ligation. The patient had undesired fert…

2428. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33698/psn-pdf
      August 01, 2010 - In Conversation with...Richard P. Shannon, MD August 1, 2010 In Conversation with..Richard P. Shannon, MD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md Editor's note: Richard P. Shannon, MD, is the Frank Wister Thomas Professor of Medicine at the University of Pe…

2429. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience | PSNet
      psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
      December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005  View more articles from the same authors. Citation Text: Conway JB, Weingart SN. Organizational Change…

2430. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33825/psn-pdf
      January 01, 2017 - Rethinking Root Cause Analysis January 1, 2016 Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis Annual Perspective 2016 Introduction Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…

2431. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience | PSNet
      psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
      July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience Karen Frush, MD | May 1, 2005  View more articles from the same authors. Citation Text: Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…

2432. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? | PSNet
      psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
      September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? Ashish K. Jha, MD, MPH | September 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Jha AK. What Can the Rest of the Heal…

2433. Human Factors Engineering Can Teach You How to Be Surprised Again | PSNet
      psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
      November 01, 2006 - Human Factors Engineering Can Teach You How to Be Surprised Again John Gosbee, MD, MS | November 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Aga…

2434. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60066/psn-pdf
      March 25, 2020 - Random chart audits, evaluating rates of over- and under- triage, analyzing triage provider interrater

2435. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care | PSNet
      psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
      November 25, 2020 - Random chart audits, evaluating rates of over- and under- triage, analyzing triage provider interrater

2436. The Role of Patient-facing Technologies to Empower Patients and Improve Safety | PSNet
      psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-improve-safety
      November 01, 2017 - August 18, 2021 Analyzing diagnostic errors in the acute setting: a process-driven approach

2437. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49808/psn-pdf
      October 01, 2017 - High-Risk Medications, High-Risk Transfers October 1, 2017 Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers The Case A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …

2438. Rescue Improvement Conference Innovation Summary | PSNet
      psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
      September 23, 2024 - Rescue Improvement Conference Innovation Summary Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL July 23, 2024 View more articles from the same authors. Innovation Contact …

2439. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-473
      March 25, 2025 - March 5, 2025 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, …

2440. Procedural Mishap: Learning Curve? | PSNet
      psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
      April 28, 2021 - Procedural Mishap: Learning Curve? Citation Text: Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. 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 En…