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Total Results: 8,619 records

Showing results for "caused".

8121. Patient Safety and Health Information Technology: Learning from Our Mistakes | PSNet
      psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
      July 01, 2012 - reduces costs has not only diminished government responsibility to set data format standards, it has also caused

8122. In Conversation With… David Blumenthal, MD, MPP | PSNet
      psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
      July 01, 2012 - reduces costs has not only diminished government responsibility to set data format standards, it has also caused

8123. In Conversation With… Ashish K. Jha, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-ashish-k-jha-md-mph
      May 01, 2013 - My sense is that if 15 years ago one said, "Errors are caused by systems," people would look at you funny

8124. In Conversation With... Michael L. Millenson | PSNet
      psnet.ahrq.gov/perspective/conversation-michael-l-millenson
      April 27, 2022 - went out into the field for a year to report on the widespread changes in American healthcare being caused

8125. Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know? | PSNet
      psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-disciplinary-actions-and-complaints-what-do-we-know
      July 01, 2017 - Trying to recover for errors caused by systems breakdowns and systems of care can be challenging.

8126. 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…

8127. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49695/psn-pdf
      October 01, 2013 - Finding Fault With the Default Alert October 1, 2013 Baysari M. Finding Fault With the Default Alert. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/finding-fault-default-alert The Case A 33-year-old man with known refractory epilepsy and developmental delay was admitted to the hospital after experiencing …

8128. Discharged Blindly | PSNet
      psnet.ahrq.gov/web-mm/discharged-blindly
      October 26, 2022 - Discharged Blindly Citation Text: Iezzoni LI. Discharged Blindly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…

8129. In Conversation With… Lorri Zipperer, MA | PSNet
      psnet.ahrq.gov/perspective/conversation-lorri-zipperer-ma
      February 26, 2025 - In Conversation With… Lorri Zipperer, MA November 1, 2015  Citation Text: In Conversation With… Lorri Zipperer, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation For…

8130. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846922/psn-pdf
      March 29, 2023 - Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes March 29, 2023 https://psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions- and-improve-health Summary With increasing recognition that health is linked to the condit…

8131. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49574/psn-pdf
      November 01, 2008 - A Mid-Summer Fog November 1, 2008 Braddock CH. A Mid-Summer Fog. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/mid-summer-fog The Case A 33-year-old woman with type I diabetes mellitus was admitted for symptoms of left flank pain, dysuria, and emesis, concerning for pyelonephritis. The patient was taking …

8132. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73554/psn-pdf
      July 28, 2021 - EMS Patient Safety in the Field July 28, 2021 Augustine JJ, Fitall E, Hall KK, et al. EMS Patient Safety in the Field. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/ems-patient-safety-field Introduction Emergency medical services (EMS) personnel serve a critical role within the care continuum. They ar…

8133. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49413/psn-pdf
      September 01, 2003 - Did We Forget Something? September 1, 2003 Gibbs VC. Did We Forget Something? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/did-we-forget-something The Case A 76-year-old-man underwent right aorto-iliac aneurysm repair. He developed postoperative fever, initially attributed to ventilator-associated pneumo…

8134. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33834/psn-pdf
      May 22, 2017 - Opioid Overdose as a Patient Safety Problem May 22, 2017 Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem Perspective Opioids serve a valuable role in the treatment of acute pain and pain associat…

8135. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
      March 01, 2009 - Spotlight Case July 2008 Spotlight Case All in the History Source and Credits This presentation is based on the February/March 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Christopher Fee, MD, University of California, San Francisco …

8136. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
      May 01, 2012 - Spotlight Case July 2008 Spotlight Case The Perils of Cross Coverage * * Source and Credits This presentation is based on the May 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, …

8137. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49406/psn-pdf
      June 01, 2003 - The Dangerous Detour June 1, 2003 Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dangerous-detour The Case Following an overdose of alcohol and Ativan, a 26-year-old woman was admitted to the Medicine service for observation after being placed on a 72-hour hold by…

8138. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73412/psn-pdf
      August 01, 2022 - “Behavioral Health Vital Signs” Initiative Increases Patient Education and Disclosure about Interpersonal Violence (IPV) June 30, 2021 https://psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and- disclosure Summary The Behavioral Health Vital Signs (BHVS) screener i…

8139. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.92_slideshow.ppt
      April 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case April 2005 Compare and Contrast Source and Credits This presentation is based on the April 2005 Spotlight Case in Emergency Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Kerry Cho, MD; Glenn Cher…

8140. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49650/psn-pdf
      March 01, 2012 - Turn the Other Cheek March 1, 2012 Starling J. Turn the Other Cheek. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/turn-other-cheek The Case A 56-year-old man underwent two skin biopsies to evaluate clinically concerning lesions. The first biopsy was diagnostic for squamous cell carcinoma (SCC) and docume…