-
psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - patient with osteoporosis and multiple
comorbidities undergoing femoral fracture repair
4
Case Details … mobilization x-rays
• The patient’s recovery was slow due to ileus and severe
deconditioning
5
Case Details … cardiac anesthesiologist, including
intraoperative trans-esophageal echocardiography (TEE)
6
Case Details … Neither a cardiac anesthesiologist nor TEE was utilized, given
the late hour of surgery
7
Case Details
-
psnet.ahrq.gov/node/34128/psn-pdf
December 23, 2016 - Please refer to the information link below for
further details.
-
psnet.ahrq.gov/node/37887/psn-pdf
July 02, 2008 - not reimburse
hospitals for care related to 28 preventable errors, though they have not specified details
-
psnet.ahrq.gov/node/43714/psn-pdf
December 17, 2014 - widely publicized delayed diagnosis of Ebola at a Dallas hospital and
reveals previously undisclosed details
-
psnet.ahrq.gov/node/41204/psn-pdf
March 07, 2012 - canadian-interprofessional-patient-safety-competencies-their-role-health-care-
professionals
This commentary details
-
psnet.ahrq.gov/node/41261/psn-pdf
May 04, 2012 - /issue/case-based-learning-patient-safety-lessons-learnt-program-uk-junior-doctors
This commentary details
-
psnet.ahrq.gov/node/41602/psn-pdf
August 15, 2012 - issue/how-can-health-care-organizations-become-more-health-literate-workshop-
summary
This report details
-
psnet.ahrq.gov/issue/patient-safety-and-acute-care-medicine-lessons-future-insights-past
April 27, 2022 - This brief review details how observations from engineering, cognitive psychology, and chess can inform
-
psnet.ahrq.gov/issue/ashp-statement-pharmacists-role-medication-reconciliation
June 30, 2021 - This statement details how pharmacists can establish and maintain medication reconciliation processes
-
psnet.ahrq.gov/issue/look-alike-sound-alike-drugs-trigger-dangers
June 29, 2016 - This news piece details errors involving medication name confusion and presents tips for consumers
-
psnet.ahrq.gov/issue/hospital-infections-hard-gauge
July 20, 2011 - This news piece details efforts to collect, analyze, and utilize state-wide reports on health care–associated
-
psnet.ahrq.gov/node/41183/psn-pdf
February 29, 2012 - increasing-use-smart-pump-drug-libraries-nurses-continuous-quality-
improvement-project
This commentary details
-
psnet.ahrq.gov/node/39580/psn-pdf
January 03, 2017 - A related editorial details the challenges inherent in implementing a complex system
change such as
-
psnet.ahrq.gov/node/41029/psn-pdf
October 06, 2016 - widespread use of mobile devices (such as iPads and smartphones) in health care, this
newspaper article details
-
psnet.ahrq.gov/node/35083/psn-pdf
March 29, 2007 - https://psnet.ahrq.gov/issue/patient-safety-achieving-new-standard-care
This report details findings
-
psnet.ahrq.gov/node/42477/psn-pdf
August 07, 2013 - investigation into care delivered at National Health Service trusts with high
mortality rates, this report details
-
psnet.ahrq.gov/issue/preventing-maternal-death
April 26, 2023 - Please refer to the information link below for further details.
-
psnet.ahrq.gov/node/42057/psn-pdf
February 20, 2013 - improving-patient-safety-operating-theatre-and-perioperative-care-obstacles-
interventions-and
This review details
-
psnet.ahrq.gov/node/43121/psn-pdf
April 16, 2014 - https://psnet.ahrq.gov/issue/implementing-safety-thermometer-tool-one-nhs-trust
This commentary details
-
psnet.ahrq.gov/node/35477/psn-pdf
November 16, 2005 - https://psnet.ahrq.gov/issue/safer-place-patients-learning-improve-patient-safety
This report details