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Showing results for "effort".

5381. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49531/psn-pdf
      March 01, 2007 - Failure to Report March 1, 2007 Spath P. Failure to Report. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/failure-report Case Objectives List common causes of medical errors. Appreciate the magnitude of underreporting of adverse events. List the common barriers to reporting adverse events and near misses…

5382. 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…

5383. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865778/psn-pdf
      May 29, 2024 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement May 29, 2024 Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/navigating-complications-unint…

5384. 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…

5385. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49588/psn-pdf
      August 01, 2009 - Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care August 1, 2009 Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care Case…

5386. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49865/psn-pdf
      June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy June 1, 2019 Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy The Case A 75-year-old man with a past medical history of hemorrhagic stroke, coron…

5387. To Transfer or Not to Transfer | PSNet
      psnet.ahrq.gov/web-mm/transfer-or-not-transfer
      November 23, 2016 - SPOTLIGHT CASE To Transfer or Not to Transfer Citation Text: Pines JM. To Transfer or Not to Transfer. 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 …

5388. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49705/psn-pdf
      January 01, 2020 - A "Reflexive" Diagnosis in Primary Care April 1, 2014 Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care Case Objectives Appreciate that primary care doctors may be caring for an increasing number of patients wi…

5389. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49676/psn-pdf
      February 01, 2013 - Death by PCA February 1, 2013 Hicks RW. Death by PCA. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/death-pca The Case A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …

5390. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865376/psn-pdf
      March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures March 27, 2024 Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…

5391. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854848/psn-pdf
      October 31, 2023 - Delay in Malignancy Diagnosis Reflects Systemic Failures October 31, 2023 Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures The Case A 32-year-old man presented to the hospital with…

5392. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49633/psn-pdf
      September 01, 2011 - The Safety and Quality of Long Term Care September 1, 2011 Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care Case Objectives Identify commonly reported adverse events in long-term care. Identify two to three challenges…

5393. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49798/psn-pdf
      July 01, 2017 - Pseudo-obstruction But a Real Perforation July 1, 2017 Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation Case Objectives Recognize acute colonic pseudo-obstruction and implement a medical management plan. Ide…

5394. 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…

5395. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33652/psn-pdf
      June 01, 2007 - Advancing Patient Safety Through State Reporting Systems June 1, 2007 Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems Perspective Seven years ago, the Institute of Medicine (I…

5396. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49437/psn-pdf
      March 01, 2004 - Crossing the Line March 1, 2004 Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/crossing-line Case Objectives Review complications of central venous catheterization Discuss patient and operator factors that affect complication rates Describe methods for preventing c…

5397. 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 …

5398. Spotlight (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
      January 01, 2019 - Spotlight Spotlight Mistaken Attribution, Diagnostic Misstep * Source and Credits This presentation is based on the January 2019 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD …

5399. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49799/psn-pdf
      July 01, 2017 - Delayed Recognition of a Positive Blood Culture July 1, 2017 Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture The Case A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress…

5400. 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…