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Total Results: 601 records

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361. Content analysis of patient safety incident reports for older adult patient transfers, handovers, and discharges: do they serve organizations, staff, or patients? | PSNet
     psnet.ahrq.gov/issue/content-analysis-patient-safety-incident-reports-older-adult-patient-transfers-handovers-and
     December 14, 2022 - Endnote tagged PubMedId RIS Download Citation Related Resources From the Same Author … February 2, 2022 Hemodialysis bleeding events and deaths: an 18-year retrospective analysis

362. The COVID-19 pandemic and dentistry: parts 1 and 2. | PSNet
     psnet.ahrq.gov/issue/covid-19-pandemic-and-dentistry-parts-1-and-2
     December 16, 2015 -   Copy Citation Related Resources From the Same Author(s) Harms

363. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867206/psn-pdf
     December 18, 2024 - Timing and Triggers Approach to the Diagnosis of Acute Dizziness Syndrome Description Benign causesa … #29 https://psnet.ahrq.gov//#29 https://psnet.ahrq.gov//#30 https://psnet.ahrq.gov//#31 Test Brief description

364. A Real Heartache | PSNet
     psnet.ahrq.gov/web-mm/real-heartache
     October 01, 2018 - The Case A 60-year-old man presented to the emergency department (ED) with 2 hours of burning chest … His past medical history was notable for a history of depression, a 40-pack/year history of cigarette … Case The Commentary References Table Figures Related Resources From the Same Author

365. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49673/psn-pdf
     December 01, 2012 - https://psnet.ahrq.gov/web-mm/real-heartache The Case A 60-year-old man presented to the emergency … His past medical history was notable for a history of depression, a 40- pack/year history of cigarette

366. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture | PSNet
     psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
     March 15, 2023 - Takeda Speaker Inhibrix Consultant Boehinger Ingelheim Consultant Astra Zeneca Consultant Theravance Author … Inhibrix Author Patrick Romano, MD, MPH; Debra Bakerjian, PhD, APRN, RN; Kathleen M Carlsen, PA; Elizabeth … The Case A 56-year-old man was admitted with Coronavirus Disease 2019 (COVID-19) pneumonia and acute … A large study of tracheostomy-related deaths over a 10-year period in the US found a higher prevalence … ventilator dependence and progressive dilation of the trachea at the tracheostomy tube cuff site. 9,10 The description

367. A "Weak" Response | PSNet
     psnet.ahrq.gov/web-mm/weak-response
     February 24, 2011 - The Case A primary care physician on call for his group received a call at 9:00PM from a 68-year-old … The patient reported also taking lisinopril 20 mg daily for more than a year. … As I tried to get a visual picture from his description, he mentioned that he had a digital camera. … Sections The Case The Commentary References Related Resources From the Same Author

368. eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds. | PSNet
     psnet.ahrq.gov/innovation/esimpler-dynamic-electronic-health-record-integrated-checklist-clinical-decision-support
     June 16, 2021 - PubMedId RIS Download Citation Related Resources From the Same Author … February 16, 2022 Reducing failure to rescue rates in a paediatric in-patient setting: a 9-year

369. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49698/psn-pdf
     December 01, 2013 - https://psnet.ahrq.gov/web-mm/snfs-opening-black-box The Case An 88-year-old woman was admitted to … STRATEGIES DESCRIPTION RESOURCES     Enhanced SNF leadership and culture of safety and quality … www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/nursing-home/index.html STRATEGIES DESCRIPTION … NHQAPI.html http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/NHQAPI.html STRATEGIES DESCRIPTION … INTERACT http://interact.fau.edu/     http://nhqualitycampaign.org http://interact.fau.edu/ STRATEGIES DESCRIPTION

370. Language Barrier | PSNet
     psnet.ahrq.gov/web-mm/language-barrier
     February 28, 2024 - than half of US high school students are enrolled in foreign language courses.( 6 ) In the case description … study comparing hospital interpreters and ad hoc interpreters, for example, found that when an 11-year-old … Lack of an interpreter for a 3-year-old girl presenting to the emergency department with abdominal … someone else" instead of "the girl hit herself" when she fell off her tricycle) resulted in a 2-year-old … The Case The Commentary References Table Related Resources From the Same Author

371. What Was in Those Platelets? | PSNet
     psnet.ahrq.gov/web-mm/what-was-those-platelets
     August 28, 2024 - The Case A 47-year-old woman was admitted to the hospital for complex spinal surgery. … On the same day, a 76-year-old man with coronary artery disease and a prosthetic aortic valve was admitted … The bacterium was never cultured from the blood of the 76-year-old man, but he remained febrile in the … Contaminated Platelet Products (N = 46 transfused platelet units). ( 14 ) Number/Percentage of Cases Description … The Case The Commentary References Tables Related Resources From the Same Author

372. In Conversation With… Lawrence Smith, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
     February 01, 2012 - RW : So you see it as a fundamental part of the hospitalist mindset and job description as opposed to … But I think it's more the hospital creating a job description for the hospitalists that serves a set … The death of 18-year-old Libby Zion at The New York Hospital in 1984 led to the recommendation by the … but not to coordinate a complex discharge transition independently until their second year. … mechanisms to objectively measure competency, which in some circumstances may be independent of the year

373. Adolescent Diabetes: A Routine Visit? | PSNet
     psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
     November 18, 2016 - Case & Commentary: Part 1 A 15-year-old adolescent presented to her pediatrician for ongoing management … The estimated incidence rates (per 100,000 person-years) of T2DM among 15- to 19-year-old youth by race … eventually can help distinguish types 1 and 2, but levels in the two types may overlap for up to a year … The patient description in the first sentence prepares us for, and may bias us toward, discounting the … Case & Commentary: Part 2 References Table Related Resources From the Same Author

374. The Hazards of Distraction: Ticking All the EHR Boxes | PSNet
     psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
     April 09, 2014 - The Case A 55-year-old woman with a history of metastatic cancer of unknown origin was sent to the … Indeed, it can be inferred from this case description that the care provider herself realized the inappropriateness … A description of the steps that should be taken to develop, design, implement, approve and maintain order … The Commentary Take-Home Points References Related Resources From the Same Author

375. High Reliability | PSNet
     psnet.ahrq.gov/primer/high-reliability
     January 29, 2020 - Characteristics of High Reliability 1,2,3,4 Characteristic Description Preoccupation With Failure Everyone … decrease in adverse events such as falls, pressure injuries, and healthcare-acquired infections one year

376. Interdisciplinary teamwork | PSNet
     psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
     July 20, 2025 - PSNet Team Date Created: October 14, 2024 Last Updated: July 20, 2025 Description … number of visits with physician-documented medication reconciliation and this increase was sustained one year … The lead author, Dr.

377. Are You Mrs. A? An Issue of Identification Over Telephone | PSNet
     psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
     January 01, 2016 - A was a 78-year-old man admitted with non-ST elevation myocardial infarction with acute kidney injury … B was a 62-year-old man admitted to the same medicine unit with hypoglycemia and a diabetic foot ulcer … Detection Method Wrong Patient Errors per 100,000 Medication Orders Type of Errors Description … and near miss errors 120 CPOE facilities that voluntarily reported medication errors in calendar year … The Case The Commentary References Table Related Resources From the Same Author

378. Anticoagulation: Held Too Long | PSNet
     psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
     April 01, 2008 - The Case A 68-year-old woman with a history of mitral valve replacement with a mechanical valve was … Estimates suggest that approximately 250,000 patients each year in North America on oral anticoagulant … For example, an 80-year-old patient with atrial fibrillation (an irregular heart rhythm that can lead … The Case The Commentary References Tables Related Resources From the Same Author … October 7, 2015 Hospital quality and patient safety competencies: development, description

379. Inadequate hand-off communication. | PSNet
     psnet.ahrq.gov/issue/inadequate-hand-communication
     April 02, 2015 - Endnote tagged PubMedId RIS Download Citation Related Resources From the Same Author … November 28, 2018 Association between handover of anesthesiology care and 1-year mortality

380. Emergent Triage Miss | PSNet
     psnet.ahrq.gov/web-mm/emergent-triage-miss
     March 06, 2015 - The Case A 42-year-old woman presented to a busy urban emergency department (ED) and approached the … Triage Level 1 Triage Level 2 Triage Level 3 Triage Level 4 Triage Level 5 Description … The Case The Commentary References Tables Related Resources From the Same Author