Results

Total Results: 525 records

Showing results for "episode".

361. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-459
     October 30, 2024 - October 2, 2024 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports…

362. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. | PSNet
     psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
     January 29, 2021 - Conclusion This patient became hypoxic during an episode of laryngospasm but fortunately did not suffer

363. An Incomplete Anesthesia History Leads to Adverse Outcomes | PSNet
     psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
     January 29, 2021 - the patient had an underlying sensitivity to succinylcholine, contributing to the response to this episode

364. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50698/psn-pdf
     November 27, 2019 - gender, ethnicity, family history of suicide), "dynamic" factors (such as an active psychotic or mood episode

365. Electronic Err | PSNet
     psnet.ahrq.gov/web-mm/electronic-err
     April 01, 2014 - Electronic Err Citation Text: Tang PC. Electronic Err. 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 7 XML Endnote tagged PubMedId RIS …

366. Triage Time Bomb | PSNet
     psnet.ahrq.gov/web-mm/triage-time-bomb
     September 01, 2008 - Triage Time Bomb Citation Text: Washington DL. Triage Time Bomb. 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 7 XML Endnote tagged PubMedId RIS …

367. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49446/psn-pdf
     August 30, 2021 - Too Tight Control May 1, 2004 Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/too-tight-control Case Objectives Appreciate the advantages and potential complications of intensive insulin therapy in the hospitalized patient List hospital-based safeguards available to…

368. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/841469/psn-pdf
     December 14, 2022 - Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. December 14, 2022 Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-mi…

369. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60952/psn-pdf
     September 30, 2020 - When the Lytes Go Out: A Case of Inpatient Cardiac Arrest September 30, 2020 Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest Disclosure of Relevant Financial Relationships: As a pr…

370. Inflicting Confusion | PSNet
     psnet.ahrq.gov/web-mm/inflicting-confusion
     August 04, 2021 - Inflicting Confusion Citation Text: Scott FI, Lichtenstein GR. Inflicting Confusion. 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 X3 XML EndNote 7 XML Endnote …

371. In Conversation With… John D. Birkmeyer, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md
     January 31, 2024 - researchers, the idea that it's not about the physician, it's about the entire team and about the entire episode

372. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
     January 01, 2024 - VF may have been induced a second time because the team did not correct the problem after the first episode

373. Spotlight
     psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
     January 01, 2024 - Spotlight Spotlight A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis 1 Source and Credits This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Garth Utter, MD, MSc, FACS…

374. Spotlight
     psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
     January 01, 2024 - Spotlight Spotlight A Fatal Twist in Pseudohyperkalemia 1 Source and Credits This presentation is based on the August 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Le…

375. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/857259/psn-pdf
     November 30, 2023 - Medication Mix-Up Leads to Patient Death November 30, 2023 Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death The Case  An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…

376. 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.” …

377. Innovations in Promoting Hand Hygiene Compliance | PSNet
     psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
     May 01, 2014 - Although the product will be dispensed on demand, only one episode of hand hygiene is recorded for every

378. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49750/psn-pdf
     January 01, 2016 - psnet.ahrq.gov/web-mm/room-without-orders prompted a formal review as, in addition to the preventable episode

379. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49611/psn-pdf
     October 01, 2010 - The patient survived the episode without any life-threatening arrhythmias and was transferred to an

380. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49717/psn-pdf
     September 01, 2014 - The nurse, reluctant to administer this medication in light of the recent episode of somnolence, attempted