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Showing results for "deaths".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49625/psn-pdf
    May 01, 2011 - Pocket Syringe Swap May 1, 2011 Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/pocket-syringe-swap The Case A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for postoperative pain management. Surgery proceeded uneventfully under…

  2. Handoffs and Transitions | PSNet

    psnet.ahrq.gov/perspective/handoffs-and-transitions
    February 01, 2007 - Annual Perspective Handoffs and Transitions Niraj Sehgal, MD, MPH | January 22, 2014  View more articles from the same authors. Citation Text: Sehgal NL. Handoffs and Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72586/psn-pdf
    December 23, 2020 - Code Status vs. Care Status December 23, 2020 Krisman RK, Spero H. Code Status vs. Care Status. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/code-status-vs-care-status Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for Continuing Medical Education (AC…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33562/psn-pdf
    September 15, 2024 - Rapid Response Systems September 15, 2024 Rapid Response Systems. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/rapid-response-systems PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field.…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49759/psn-pdf
    May 01, 2016 - Falling Through the Crack (in the Bedrails) May 1, 2016 Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/falling-through-crack-bedrails Case Objectives Review the epidemiology of patient falls and associated injuries in the hospital set…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865466/psn-pdf
    March 27, 2024 - Equity in Patient Safety March 27, 2024 Thomas A, Lee M, Mossburg S. Equity in Patient Safety. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/equity-patient-safety Introduction Safety and equity are among the central components that determine quality of care, according to nonprofit advisory agencies l…

  7. Difficult Encounters: A CMO and CNO Respond | PSNet

    psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
    March 01, 2018 - SPOTLIGHT CASE Difficult Encounters: A CMO and CNO Respond Citation Text: Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: …

  8. Equity in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/equity-patient-safety
    September 24, 2024 - Annual Perspective Equity in Patient Safety Angela D. Thomas, DrPH, MPH, MBA; Merton Lee, PhD, PharmD; Sarah Mossburg, RN, PhD | March 27, 2024  View more articles from the same authors. Citation Text: Thomas A, Lee M, Mossburg S. Equity in Patient Safety. …

  9. Spotlight

    psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
    January 01, 2025 - Spotlight Spotlight Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations  1 Source and Credits This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Samantha Brown…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850361/psn-pdf
    June 14, 2023 - Critical Echocardiogram Result Lost to Follow-up June 14, 2023 Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow The Case A 63-year-old man with history of stroke, systolic heart failure, and ventric…

  11. Key Issues in Developing a Successful Hospital Safety Program | PSNet

    psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program
    July 01, 2006 - In 1997, Newton-Wellesley Hospital had two highly publicized maternal deaths in the space of a week. … Because one of the deaths may have been drug-related, the hospital created a position of medication management

  12. In Conversation with...Allan Frankel, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
    July 01, 2006 - In 1997, Newton-Wellesley Hospital had two highly publicized maternal deaths in the space of a week. … Because one of the deaths may have been drug-related, the hospital created a position of medication management

  13. In Conversation with...Lucian Leape, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
    August 01, 2006 - pointing to major problems in anesthesia safety and a 1982 episode of ABC's 20/20 that dramatized deaths … Yet, those who have lived through the past few decades of anesthesia's evolution know that the deaths

  14. Bleeding Risk | PSNet

    psnet.ahrq.gov/web-mm/bleeding-risk
    November 01, 2003 - Bleeding Risk Citation Text: Crowther MA. Bleeding Risk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49872/psn-pdf
    August 08, 2019 - Spinal Epidural Abscess August 8, 2019 Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spinal-epidural-abscess The Case A 30-year-old woman with a history of prior spine surgery presented to the emergency department with a few days of progressive low back pain. She…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50930/psn-pdf
    February 21, 2020 - Pharmacist Role in Patient Safety February 21, 2020 Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/pharmacist-role-patient-safety Background: The Evolving Role of the Pharmacist Medication errors are highly pervasive across all settings of care,[1] w…

  17. Acute Care Admission of the Behavioral Health Patient | PSNet

    psnet.ahrq.gov/web-mm/acute-care-admission-behavioral-health-patient
    July 19, 2023 - Acute Care Admission of the Behavioral Health Patient Citation Text: Weiss AP, Rosenbaum JF. Acute Care Admission of the Behavioral Health Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: …

  18. Two Pills, Same Drug | PSNet

    psnet.ahrq.gov/web-mm/two-pills-same-drug
    May 27, 2011 - Two Pills, Same Drug Citation Text: Horsky J, Patel VL. Two Pills, Same Drug. 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 …

  19. Right Electrocardiogram, Wrong Patient | PSNet

    psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
    April 24, 2024 - Right Electrocardiogram, Wrong Patient Citation Text: Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX EndNote…

  20. Lapse in Antibiotics Leads to Sepsis | PSNet

    psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
    November 21, 2021 - Lapse in Antibiotics Leads to Sepsis Citation Text: Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …
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