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Showing results for "defining".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49645/psn-pdf
    February 01, 2012 - E-prescribing: E for error? February 1, 2012 Ashton EW. E-prescribing: E for error? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/e-prescribing-e-error Case Objectives Define e-prescribing. Describe ways in which e-prescribing can reduce health care costs. State how commonly prescription errors occur wit…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49450/psn-pdf
    June 01, 2004 - The Wrong Shot: Error Disclosure June 1, 2004 Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure Case Objectives Describe the rationale for disclosing harmful errors to patients. Describe the specific information that patie…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49654/psn-pdf
    June 01, 2012 - Transfer Troubles June 1, 2012 Hains IM. Transfer Troubles. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfer-troubles Case Objectives Recognize that transfer of patients between hospitals is common. Understand the frequency of errors and adverse events in the transfer of patients between hospitals. …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49828/psn-pdf
    May 01, 2018 - Out of Sight, Out of Mind: Out-of-Office Test Result Management May 1, 2018 Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management Case Objectives Recognize the general responsibilities of…

  5. Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx Spotlight Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities Source and Credits • This presentation is based on the March 2023 AHRQ WebM&M Spotlight Case o See the full article at https://…

  6. Emergency Error | PSNet

    psnet.ahrq.gov/web-mm/emergency-error
    January 18, 2013 - SPOTLIGHT CASE Emergency Error Citation Text: Symons NRA. Emergency Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49550/psn-pdf
    December 01, 2007 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? December 1, 2007 Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals The Case …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33754/psn-pdf
    September 01, 2013 - In Conversation With… Sidney Dekker, MA, MSc, PhD September 1, 2013 In Conversation With… Sidney Dekker, MA, MSc, PhD. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd Editor's note: Sidney Dekker is Professor and Director of the Safety Science Innovation Lab at Grif…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50392/psn-pdf
    September 01, 2019 - In Conversation With… Shantanu Agrawal, MD, MPhil September 1, 2019 In Conversation With… Shantanu Agrawal, MD, MPhil. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil Editor's note: Dr. Agrawal is president and CEO of the National Quality Forum (NQF). He is the form…

  10. The Hazards of Distraction: Ticking All the EHR Boxes | PSNet

    psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
    April 09, 2014 - SPOTLIGHT CASE The Hazards of Distraction: Ticking All the EHR Boxes Citation Text: Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation …

  11. Innovations | PSNet

    psnet.ahrq.gov/innovations
    February 26, 2025 - Innovations The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …

  12. Treatment Challenges After Discharge | PSNet

    psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
    January 03, 2017 - SPOTLIGHT CASE Treatment Challenges After Discharge Citation Text: Coffey C. Treatment Challenges After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar Bib…

  13. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
    January 01, 2023 - Spotlight Spotlight Prolonged DKA in Pregnancy: A Case of Communication Breakdown Source and Credits • This presentation is based on the August 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Sarah Marshall, MD and Nina M. …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49573/psn-pdf
    January 01, 2009 - Dangerous Shift November 1, 2008 Patterson ES. Dangerous Shift. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dangerous-shift Case Objectives Review the evidence base on erroneous actions related to shift changes. Understand the limits of standardizing handoffs in preventing errors at shift change. Expla…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49819/psn-pdf
    February 01, 2018 - Signout Fallout February 1, 2018 Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/signout-fallout Case Objectives Understand the role of communication failures in medical errors and preventable adverse events. Review the evidence in support of handoff improvement pr…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49760/psn-pdf
    May 01, 2016 - Mismanagement of Delirium May 1, 2016 Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/mismanagement-delirium The Case An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although fitted with a cast at a regional ho…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49698/psn-pdf
    December 01, 2013 - SNFs: Opening the Black Box December 1, 2013 Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/snfs-opening-black-box The Case An 88-year-old woman was admitted to a skilled nursing facility (SNF) after a lengthy hospitalization for a small bowel obstructio…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33774/psn-pdf
    December 01, 2014 - In Conversation With… Edward Kelley, PhD December 1, 2014 In Conversation With… Edward Kelley, PhD. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-edward-kelley-phd Editor's note: Edward Kelley, PhD, is Director of Service Delivery and Safety for the World Health Organization (WHO). He ha…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60745/psn-pdf
    October 01, 2020 - Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia July 29, 2020 Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/multiple-high-risk-events-involvi…

  20. Spinal Epidural Abscess | PSNet

    psnet.ahrq.gov/web-mm/spinal-epidural-abscess
    November 13, 2019 - Spinal Epidural Abscess Citation Text: Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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