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Showing results for "educational".

  1. 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…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853773/psn-pdf
    September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side. September 27, 2023 Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side The Case A first-year orthopedic surgery resident was consulted…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33704/psn-pdf
    December 01, 2010 - In Conversation with...Geri Amori, PhD December 1, 2010 In Conversation with..Geri Amori, PhD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd Editor's note: Geri Amori, PhD, is Vice President for the Education Center at The Risk Management and Patient Safety Institute, a…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33663/psn-pdf
    September 15, 2008 - Implementing a Patient Safety Program at a Large National Health System January 1, 2008 Hauck LD, Jacob J. Implementing a Patient Safety Program at a Large National Health System. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system Perspectiv…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49608/psn-pdf
    August 01, 2010 - Emergent Triage Miss August 1, 2010 Travers D. Emergent Triage Miss. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/emergent-triage-miss The Case A 42-year-old woman presented to a busy urban emergency department (ED) and approached the triage nurse. The patient told the triage nurse that she had "3 days o…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33664/psn-pdf
    March 01, 2008 - In Conversation with...Bradley T. Rosen, MD, MBA March 1, 2008 In Conversation with..Bradley T. Rosen, MD, MBA. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba Editor's note: Dr. Rosen is Medical Director of the Inpatient Specialty Program (ISP) Hospitalist service…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836841/psn-pdf
    June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission April 7, 2022 https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and- paramedics-provide-home Sum…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49702/psn-pdf
    March 01, 2014 - Tough Call: Addressing Errors From Previous Providers March 1, 2014 Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers Case Objectives Define what it means to be a professional. Identi…

  9. Good Catch in the Operating Room | PSNet

    psnet.ahrq.gov/web-mm/good-catch-operating-room
    August 27, 2017 - Good Catch in the Operating Room Citation Text: Day J, Paige JT. Good Catch in the Operating Room. 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 …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49829/psn-pdf
    May 01, 2018 - Root Cause Analysis Gone Wrong May 1, 2018 Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney transplant. A suitabl…

  11. The Wrong Shot: Error Disclosure | PSNet

    psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
    May 01, 2011 - SPOTLIGHT CASE The Wrong Shot: Error Disclosure Citation Text: Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Sch…

  12. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose | PSNet

    psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
    March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose Citation Text: Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846563/psn-pdf
    March 21, 2023 - Impact of System Failures on Healthcare Workers March 21, 2023 Zangaro G, Van CM, Mossburg S. Impact of System Failures on Healthcare Workers . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers Introduction The March 2022 conviction of RaDonda Vaught, a former nu…

  14. The Hidden Danger of Unseen Intravenous Catheters | PSNet

    psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
    October 04, 2023 - The Hidden Danger of Unseen Intravenous Catheters Citation Text: Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google S…

  15. Breakage of a PICC Line | PSNet

    psnet.ahrq.gov/web-mm/breakage-picc-line
    June 21, 2023 - SPOTLIGHT CASE Breakage of a PICC Line Citation Text: Dimov V. Breakage of a PICC Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …

  16. Medication Mix-Up: From Bad to Worse | PSNet

    psnet.ahrq.gov/web-mm/medication-mix-bad-worse
    March 01, 2018 - Medication Mix-Up: From Bad to Worse Citation Text: Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote …

  17. Standard Deviations | PSNet

    psnet.ahrq.gov/web-mm/standard-deviations
    January 01, 2006 - SPOTLIGHT CASE Standard Deviations Citation Text: Sabin JE. Standard Deviations. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…

  18. Hyperglycemia and Switching to Subcutaneous Insulin | PSNet

    psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
    May 19, 2021 - Hyperglycemia and Switching to Subcutaneous Insulin Citation Text: Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Sc…

  19. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists | PSNet

    psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
    February 26, 2025 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists Citation Text: Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…

  20. Too Tight Control | PSNet

    psnet.ahrq.gov/web-mm/too-tight-control
    March 20, 2013 - SPOTLIGHT CASE Too Tight Control Citation Text: Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…
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