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psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
December 31, 2024 - SPOTLIGHT CASE
Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism
Citation Text:
McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
August 21, 2024 - Although the radiologist prudently went to the emergency department to seek help for his illness, problems … self-prescription risks both drug dependency and failure by the physicians to seek professional help for mental problems … )
Physicians who treat other doctors need knowledge about physicians' reaction to illness and the problems
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - Korean janitorial shift workers found that long working hours increased the number of reported health problems … Vigilantly monitor respiration and hemodynamics after a spinal/epidural The patient in this case was … The error was fortunately discovered before the patient stopped breathing. … The effects of workplace rest breaks on health problems related to long working hours and shift work
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - Multiple systemic problems were found from the three-part process for each diagnosis. … February 20, 2019
Millions of people used tainted breathing machines.
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psnet.ahrq.gov/perspective/evidence-based-physical-examination-patient-safety-practice
November 01, 2012 - The Evidence-Based Physical Examination as a Patient Safety Practice
Steven McGee, MD | November 1, 2012
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Citation Text:
McGee S. The Evidence-Based Physical Examination as a Patient Safety Pract…
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psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
October 24, 2021 - All of it was meant for consumers, and I shared a lot of information on dispensing errors and problems … on paper or the hospital faxed a prescription to your local pharmacy, what were the patient safety problems … pharmacy uses barcoding and receives prescriptions electronically today, so we don't have the same problems
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psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - SPOTLIGHT CASE
A Missed Bowel Perforation - the Importance of Diagnostic Reasoning
Citation Text:
Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…
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psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
February 26, 2025 - leading to situation assessment with the goal of identifying safety threats quickly and responding before problems … I also research some of the pressing problems around patient experience, patient-centered care, burnout … They intentionally deferred to the expertise of the respiratory therapists in all things breathing, whether … failure to think thoroughly enough about the complex, organizational determinants that condition the problems … ,” we have to work on how we are going to marshal tools in a high reliability-oriented way to solve problems
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psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
February 26, 2025 - I also research some of the pressing problems around patient experience, patient-centered care, burnout … They intentionally deferred to the expertise of the respiratory therapists in all things breathing, whether … failure to think thoroughly enough about the complex, organizational determinants that condition the problems … ,” we have to work on how we are going to marshal tools in a high reliability-oriented way to solve problems … leading to situation assessment with the goal of identifying safety threats quickly and responding before problems
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psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
January 22, 2020 - A safe environment is one in which in team members trust and support each other, defects and problems … focused discussion between manager and worker highlighting positive aspects of work and also candor about problems
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - purpose of telemetry monitoring is to observe ECG waveforms, not serve as a substitute for assessment of breathing … Such an interprofessional team should discuss all potential problems including lack of staff availability
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psnet.ahrq.gov/primer/covid-19-and-dentistry-challenges-and-opportunities-providing-safe-care
February 24, 2022 - droplets, as well as aerosols and fomites. 11,12 Importantly, emerging evidence shows that normal breathing … patients resulted in lower dental care utilization and higher emergency department utilization for dental problems … needed to help determine the technology needs, criteria for reimbursement, and types of oral healthcare problems … The prevalence of occupational health-related problems in dentistry: A review of the literature.
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psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - In this case, four significant problems led to the alignment of the “holes” in the “slices” of the Swiss
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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - She had pulled out the nasogastric tube and the endotracheal (breathing) tube, and her leg was stuck … She has serious, complex, and multiple medical problems and requires both a fall prevention plan and
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psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
July 01, 2004 - Hip Fractures in Older Patients: the Case for Geriatrics Comanagement
Citation Text:
Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
September 01, 2015 - Good Night's Sleep Gone Wrong
Citation Text:
Gillis CM, Degrado J, Anger KE. Good Night's Sleep Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - Getting the Diagnosis Both Right and Wrong
Citation Text:
Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
June 01, 2003 - Again, while this ameliorates the situation in the ICU, it often exacerbates staffing problems in the
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psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - operationalize such an open-minded culture and decrease the likelihood that unresolved or unexplained problems
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psnet.ahrq.gov/perspective/remote-patient-monitoring
March 15, 2023 - Sarah Mossburg: With technology, sometimes we find glitches and problems once we start using it. … With the evolution from pen and paper to connected devices, have you run into problems? … For chronic obstructive pulmonary disease (COPD), you can monitor breathing, pulse oximeter numbers, … Historically, these are acute problems that arise where there is illness or injury. … We knew there were hospital capacity problems and a lot of different pressures and stakeholders that