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Showing results for "caused".

7661. How incident reporting systems can stimulate social and participative learning: a mixed-methods study. | PSNet
      psnet.ahrq.gov/issue/how-incident-reporting-systems-can-stimulate-social-and-participative-learning-mixed-methods
      November 04, 2020 - Study How incident reporting systems can stimulate social and participative learning: a mixed-methods study. Citation Text: de Kam D, Kok J, Grit K, et al. How incident reporting systems can stimulate social and participative learning: a mixed-methods study. Health Policy (New York). 202…

7662. NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme. | PSNet
      psnet.ahrq.gov/issue/nhs-learning-deaths-reports-qualitative-and-quantitative-document-analysis-first-year
      February 22, 2023 - Study NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme. Citation Text: Brummell Z, Vindrola-Padros C, Braun D, et al. NHS ‘Learning from Deaths’ reports: a qualitative and quantitative documen…

7663. Workplace verbal abuse, nurse-reported quality of care, and patient safety outcomes among early-career hospital nurses. | PSNet
      psnet.ahrq.gov/issue/workplace-verbal-abuse-nurse-reported-quality-care-and-patient-safety-outcomes-among-early
      July 10, 2019 - Study Workplace verbal abuse, nurse-reported quality of care, and patient safety outcomes among early-career hospital nurses. Citation Text: Cho H, Pavek K, Steege LM. Workplace verbal abuse, nurse‐reported quality of care and patient safety outcomes among early‐career hospital nurses. …

7664. The contribution of staffing to medication administration errors: a text mining analysis of incident report data. | PSNet
      psnet.ahrq.gov/issue/contribution-staffing-medication-administration-errors-text-mining-analysis-incident-report
      December 21, 2022 - Study The contribution of staffing to medication administration errors: a text mining analysis of incident report data. Citation Text: Härkänen M, Vehviläinen‐Julkunen K, Murrells T, et al. The Contribution of Staffing to Medication Administration Errors: A Text Mining Analysis of Incide…

7665. Patterns in medication incidents: a 10-yr experience of a cross-national anaesthesia incident reporting system. | PSNet
      psnet.ahrq.gov/issue/patterns-medication-incidents-10-yr-experience-cross-national-anaesthesia-incident-reporting
      January 15, 2025 - Study Patterns in medication incidents: a 10-yr experience of a cross-national anaesthesia incident reporting system. Citation Text: Sanduende-Otero Y, Villalón-Coca J, Romero-García E, et al. Patterns in medication incidents: A 10-yr experience of a cross-national anaesthesia incident r…

7666. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848108/psn-pdf
      April 26, 2023 - Capnography can detect hypoventilation caused by decreased respiratory drive leading to a rise in end-tidal

7667. In Conversation With… David Juurlink, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
      May 22, 2017 - Obviously that plus marketing plus lack of an appreciation of the risk caused us to go too far in one

7668. Opioid Overdose as a Patient Safety Problem | PSNet
      psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
      May 01, 2017 - Obviously that plus marketing plus lack of an appreciation of the risk caused us to go too far in one

7669. Update on Safety Culture | PSNet
      psnet.ahrq.gov/perspective/update-safety-culture
      January 22, 2020 - Update on Safety Culture Allan Frankel, MD, and Michael Leonard, MD | August 22, 2013  View more articles from the same authors. Citation Text: Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qual…

7670. X-ray Flip | PSNet
      psnet.ahrq.gov/web-mm/x-ray-flip
      August 10, 2019 - X-ray Flip Citation Text: Shapiro MJ. X-ray Flip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Downl…

7671. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49586/psn-pdf
      May 01, 2009 - Vial Mistakes Involving Heparin May 1, 2009 Vanderveen T. Vial Mistakes Involving Heparin. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin The Case A 65-year-old man was admitted to the hospital for an elective left carotid endarterectomy. During the procedure, the surgeon re…

7672. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865698/psn-pdf
      April 24, 2024 - Patient Safety Amid Nursing Workforce Challenges April 24, 2024 Leary KB, Lee M, Mossburg S. Patient Safety Amid Nursing Workforce Challenges . PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges Introduction Nurses are essential to patient care, and having a…

7673. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33856/psn-pdf
      April 01, 2018 - Patient Safety During Hospital Discharge April 1, 2018 Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge Perspective Patients are admitted to the hospital in the United States 35 million times per year.(1)…

7674. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49575/psn-pdf
      November 01, 2008 - Sick and Pregnant November 1, 2008 El-Ibiary S. Sick and Pregnant. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/sick-and-pregnant The Case A 35-year-old woman with chronic asthma presented to the emergency department (ED) with difficulty breathing. The patient informed the staff that she was 17 weeks pre…

7675. Looking for Meds in All the Wrong Places | PSNet
      psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
      June 16, 2021 - Looking for Meds in All the Wrong Places Citation Text: Manias E. Looking for Meds in All the Wrong Places. 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 XML…

7676. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49788/psn-pdf
      March 01, 2017 - Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention March 1, 2017 Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention The Case A 48-year…

7677. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49453/psn-pdf
      July 01, 2004 - Bowel Prep July 1, 2004 Nelson D. Bowel Prep. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/bowel-prep The Case The patient is a 73-year-old woman who 20 years ago underwent treatment for breast cancer. At her daughter's suggestion, the patient requested referral for colonoscopy, as she understood there w…

7678. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866846/psn-pdf
      September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement September 24, 2024 Stockmeier CA, Thomas E, Mossburg S, et al. Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/zero…

7679. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49844/psn-pdf
      October 01, 2018 - Diffusion of Responsibility Leads to Danger October 1, 2018 Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger The Case A 70-year-old man was sent to the emergency department (ED) from a nursing facility…

7680. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49447/psn-pdf
      June 01, 2004 - Dangerous Dapsone June 1, 2004 Bookwalter T. Dangerous Dapsone. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/dangerous-dapsone The Case A 78-year-old woman with newly diagnosed multiple myeloma on corticosteroids presented to the emergency department with dyspnea. Upon admission, she was found to be hypo…