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Showing results for "establishing".

1781. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49483/psn-pdf
      June 01, 2005 - Getting to the Root of the Matter June 1, 2005 Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/getting-root-matter Case Objectives Appreciate the goals and limitations of root cause analysis Outline the steps to conduct root cause analysis The Case A…

1782. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72516/psn-pdf
      November 25, 2020 - Premature Closure: Was It Just Syncope? November 25, 2020 Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…

1783. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
      January 01, 2022 - Spotlight Spotlight Intraosseous Line Extravasation in a Pediatric Trauma Patient Source and Credits • This presentation is based on the April 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: David Barnes, MD and Joseph Yoon, MD o…

1784. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/857061/psn-pdf
      November 27, 2023 - In Conversation with... Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety November 27, 2023 Stanley J. In Conversation with.. Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-joa…

1785. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73128/psn-pdf
      July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients. April 7, 2021 https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications- and-enhances Summary The Hospital at Homesm program provides hospital-level care…

1786. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73102/psn-pdf
      July 01, 2022 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use March 31, 2021 https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail- community-dwelling Summary Care management staff (such …

1787. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33859/psn-pdf
      June 01, 2018 - In Conversation With… Richard Hoppmann, MD June 1, 2018 In Conversation With… Richard Hoppmann, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-richard-hoppmann-md Editor's note: Dr. Hoppmann is the Dorothea H. Krebs Endowed Chair of Ultrasound Education, Professor of Medicine, and Dire…

1788. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/845971
      January 01, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Value and Patient Safety Curated Library Foundations Safety is the preservation of value. Vandeskog B. J Safety Res. 2024;89:105-115. Safety is at the heart of safety science, and yet “safety” lacks a consensus definition among safety resea…

1789. Getting to the Root of the Matter | PSNet
      psnet.ahrq.gov/web-mm/getting-root-matter
      September 01, 2005 - SPOTLIGHT CASE Getting to the Root of the Matter Citation Text: Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Schola…

1790. Syringe Swap During Regional Block: A Case of Medication Error and Recovery | PSNet
      psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
      July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery Citation Text: Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…

1791. In Conversation With… Susan Haas, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
      March 01, 2019 - Vision and Leadership Setting strategic goals and establishing values and a focus on safety at the

1792. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49503/psn-pdf
      February 01, 2006 - Workaround Error February 1, 2006 Pape T. Workaround Error. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/workaround-error The Case A retired 81-year-old physician with metastatic colon cancer was admitted to an acute care hospital with pneumonia and congestive heart failure (CHF). After his acute hospita…

1793. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
      October 01, 2010 - Spotlight Case July 2008 Spotlight Case October 2010 Dangerous Dialysis * * Source and Credits This presentation is based on the October 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jean L. Holley, MD, University of Illinois, Urbana-…

1794. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33778/psn-pdf
      March 01, 2015 - Diagnostic Errors January 1, 2014 Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/diagnostic-errors Annual Perspective 2014 Until very recently, diagnostic errors received relatively little attention in the field of patient safety, particularly when compared wi…

1795. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49563/psn-pdf
      May 01, 2008 - Is It Safe to Be Direct? May 1, 2008 Kulkarni NS, Williams M. Is It Safe to Be Direct? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/it-safe-be-direct The Case   A 92-year-old man with hypertension and heart failure (HF) was evaluated by his primary care physician (PCP) for progressive shortness of breat…

1796. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49730/psn-pdf
      April 01, 2015 - Transition to Nowhere April 1, 2015 Farrell TW. Transition to Nowhere. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/transition-nowhere The Case A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension, and chronic kidney disease was admitted to the hospital …

1797. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49488/psn-pdf
      August 21, 2005 - PCA Overdose August 21, 2005 Doyle JD. PCA Overdose. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/pca-overdose The Case A 49-year-old woman underwent an uneventful total abdominal hysterectomy bilateral salpingo- oophorectomy. Postoperatively, the patient complained of severe pain and received intravenou…

1798. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49841/psn-pdf
      September 01, 2018 - Chemotherapy Administration Safety Standards September 1, 2018 Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards The Case A 67-year-old woman with cancer was admitted to the hospital to begin a chemotherapy…

1799. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49845/psn-pdf
      October 01, 2018 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages October 1, 2018 Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages The Case A 1-month-old preterm infant in the ne…

1800. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49469/psn-pdf
      December 01, 2004 - Overriding Considerations December 1, 2004 Holtzman NA. Overriding Considerations. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/overriding-considerations The Case Mrs. G visited her obstetrician for first trimester routine prenatal care. The obstetrician offered genetic testing for a variety of condition…