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psnet.ahrq.gov/issue/radiation-therapy-safety-critical-role-radiation-therapist
June 20, 2014 - Summarizing the role of radiation therapists and challenges they face, this white paper details best
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psnet.ahrq.gov/node/40037/psn-pdf
September 20, 2011 - never-events
https://psnet.ahrq.gov/issue/medicares-decision-withhold-payment-hospital-errors-devil-details
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psnet.ahrq.gov/node/40020/psn-pdf
September 20, 2011 - Presented by the surgeon himself, the article details the factors
that led to the error, including production
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psnet.ahrq.gov/node/37004/psn-pdf
July 08, 2008 - outpatient investigations were not completed,
frequently because the discharge summary did not contain details
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psnet.ahrq.gov/node/41131/psn-pdf
February 15, 2012 - The article also
details types of new errors induced by CPOE systems, which, while common, were generally
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psnet.ahrq.gov/node/35407/psn-pdf
September 11, 2009 - The details of such a system, the cost impact, and
examples of how it might operationally function are
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psnet.ahrq.gov/node/44164/psn-pdf
November 03, 2015 - A related editorial
details the types of disclosure that foster transparency while upholding the need
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psnet.ahrq.gov/node/40038/psn-pdf
December 23, 2016 - Please refer to the information link below for further details.
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psnet.ahrq.gov/node/41795/psn-pdf
September 07, 2016 - Although the details
leading to the voluntary facility shutdown were not transparent, the authors suggest
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psnet.ahrq.gov/node/34775/psn-pdf
February 07, 2019 - He goes on to share his personal experience with the health care system in describing the
details of
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psnet.ahrq.gov/node/44586/psn-pdf
June 21, 2016 - This update to a prior report from AHRQ details and confirms the
declining rates in HACs between 2010
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
January 01, 2023 - following neck surgery and approaches for managing
postoperative cervical hematomas
4
Case #1 Details … notified regarding neck
swelling and evaluated the patient one hour before discharge.
5
Case #1 Details … of the upper airway, which was the suspected cause of respiratory and cardiac
arrest.
6
Case #2 Details … •
7
Case #2 Details (4)
• The following morning, the patient called the surgery clinic to report
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psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
January 29, 2021 - For this reason, the responsibility of obtaining such details falls on both the surgical and anesthesia … The details of the case should be recorded online so that this information can be accessed by future … Airway.” 17 The patient sometimes only remembers that there was a problem but does not recall the details … Giving the patient a card with the access details for the online difficult airway registry and a MedicAlert
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psnet.ahrq.gov/issue/patient-safety-achieving-new-standard-care
January 04, 2009 - This report details findings and recommendations related to establishing a national health information
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psnet.ahrq.gov/issue/eau-policy-live-surgery-events
December 29, 2014 - This policy statement details organizational requirements and provides a checklist to help ensure that
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psnet.ahrq.gov/issue/latency-ecg-displays-hospital-telemetry-systems-science-advisory-american-heart-association
March 14, 2018 - This commentary details how the delay of electrocardiogram data distributed via wireless telemetry systems
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psnet.ahrq.gov/issue/patient-safety-act
November 09, 2011 - The document details development of Patient Safety Organizations and the plans to establish a network
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psnet.ahrq.gov/issue/flaws-clinical-reasoning-common-cause-diagnostic-error
September 30, 2012 - illustrative case report, this commentary describes how cognitive biases may lead to diagnostic errors and details
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psnet.ahrq.gov/issue/quality-patient-safety-and-cardiac-surgical-team
October 07, 2013 - This review discusses the importance of improving health care quality and safety and details several
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psnet.ahrq.gov/issue/simulator-based-crew-resource-management-training-interhospital-transfer-critically-ill
February 14, 2024 - The article provides details on the potential safety hazards that were identified and addressed through