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Showing results for "consequences".

  1. Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
    January 01, 2023 - supplements for a patient on furosemide is routine, however, this same drug may lead to life-threatening consequences … • Numerous barriers to reporting exist including fear of consequences, a culture of blame, perception

  2. Code Status vs. Care Status | PSNet

    psnet.ahrq.gov/web-mm/code-status-vs-care-status
    September 30, 2020 - For example, a patient may demonstrate appreciation by verbalizing the consequences to themselves by … Cognitive underspecification: Its variety and consequences. In B. J. 

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866848/psn-pdf
    September 25, 2024 - Those factors could help them avoid some of the negative unintended consequences of zero harm goals

  4. In Conversation With… Rebecca Smith-Bindman, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-rebecca-smith-bindman-md
    October 01, 2013 - On the other hand, the risks of adverse consequences are often difficult to estimate (they generally

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49802/psn-pdf
    August 01, 2017 - Add-on Case and the Missing Checklist August 1, 2017 Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/add-case-and-missing-checklist The Case A 65-year-old woman was admitted for evaluation of abdominal pain and weight loss. Based on diagnostic data and ima…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49614/psn-pdf
    November 01, 2010 - Reconciling Records November 1, 2010 Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/reconciling-records The Cases   Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local teaching hospital. When discharged, h…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49726/psn-pdf
    March 01, 2015 - Two Wrongs Don't Make a Right (Kidney) March 1, 2015 DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney Case Objectives Review the current definition of wrong-site surgery. Describe the incidence of wrong-site surgery, and the…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49616/psn-pdf
    December 01, 2010 - Milliliters vs. Milligrams December 1, 2010 Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams The Case   A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His evaluation showed acu…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33628/psn-pdf
    February 01, 2006 - In Conversation with…John Banja, PhD February 1, 2006 In Conversation with…John Banja, PhD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withjohn-banja-phd Editor's Note: John Banja, PhD, is Assistant Director for Health Sciences and Clinical Ethics and Associate Professor of Clinical Et…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49394/psn-pdf
    April 01, 2003 - Premature or Overdue? April 1, 2003 Thomas J, Hannah M. Premature or Overdue? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/premature-or-overdue The Case A 32-year-old woman, gravida 3, para 1, presented for prenatal care at 24 weeks. Her past medical history was unremarkable, and results of her prenatal …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49680/psn-pdf
    March 01, 2013 - Pathologic Mistake March 1, 2013 Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/pathologic-mistake The Case A 32-year-old previously healthy woman experienced abdominal pain and bloating for 6 months. The discomfort worsened with eating. After losing 15 pounds …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33634/psn-pdf
    May 04, 2006 - The Wild West: Patient Safety in Office-Based Anesthesia May 1, 2006 Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild West: Patient Safety in Office-Based Anesthesia. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia Perspective Over the last decade, sur…

  13. 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 …

  14. Safety in Radiology | PSNet

    psnet.ahrq.gov/perspective/safety-radiology
    October 01, 2013 - On the other hand, the risks of adverse consequences are often difficult to estimate (they generally

  15. COVID-19 and the Built Environment | PSNet

    psnet.ahrq.gov/perspective/covid-19-and-built-environment
    June 30, 2021 - I am very, very concerned about the impact over staff burnout on patient safety or unintended consequences … Following COVID-19 timeline, what is the impact on patient safety of all these unintended consequences

  16. In Conversation with...Steven J. Spear, DBA, MS, MS | PSNet

    psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
    August 01, 2009 - Unfortunately, there are unintended, negative consequences of workarounds. … feedback to staff about the actions taken, monitor that the fix worked, and resolve any unintended consequences

  17. Workarounds and Resiliency on the Front Lines of Health Care | PSNet

    psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
    August 01, 2009 - Unfortunately, there are unintended, negative consequences of workarounds. … feedback to staff about the actions taken, monitor that the fix worked, and resolve any unintended consequences

  18. In Conversation with…Vineet Arora, MD, MA | PSNet

    psnet.ahrq.gov/perspective/conversation-withvineet-arora-md-ma
    March 01, 2011 - documents that handovers often lack important elements, and that poor quality handovers can cause adverse consequences … Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008;168:1755-1760.

  19. In Conversation With... Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA | PSNet

    psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-facha
    June 30, 2021 - I am very, very concerned about the impact over staff burnout on patient safety or unintended consequences … Following COVID-19 timeline, what is the impact on patient safety of all these unintended consequences

  20. On the Other Hand | PSNet

    psnet.ahrq.gov/web-mm/other-hand
    December 12, 2012 - reminders) may help prevent errors but should be studied for acceptability, utility, and unexpected consequences
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