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Total Results: 6,014 records

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5541. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49821/psn-pdf
      February 01, 2018 - Right Place, Right Drug, Wrong Strength February 1, 2018 Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength The Case A 2-year-old girl was admitted to a hospital burn unit for a 10% total body surface area bur…

5542. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49805/psn-pdf
      September 01, 2017 - The Forgotten Radiographic Read September 1, 2017 Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/forgotten-radiographic-read The Case A 60-year-old woman with peripheral artery disease and chronic mesenteric ischemia was admitted for management of inferior…

5543. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836942/psn-pdf
      April 27, 2022 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room April 27, 2022 Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-m…

5544. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33623/psn-pdf
      December 01, 2005 - The Unintended Consequences of Florida Medical Liability Legislation December 1, 2005 Barach P. The Unintended Consequences of Florida Medical Liability Legislation. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation Perspective Quality health …

5545. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49551/psn-pdf
      December 01, 2007 - Too Hot For Comfort December 1, 2007 Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/too-hot-comfort The Case A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV antibiotics via a peripheral line in the left antec…

5546. Spotlight Case (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
      August 01, 2012 - Spotlight Case Spotlight Case No News May Not Be Good News 1 2 Source and Credits This presentation is based on the August 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Carlton R. Moore, MD, MS; University of North Carolina, School of Medicin…

5547. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49659/psn-pdf
      July 01, 2012 - Sloppy and Paste July 1, 2012 Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/sloppy-and-paste The Case A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new onset chest pain. The ED physician reviewed the patient's electronic me…

5548. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49438/psn-pdf
      March 05, 2004 - OR Peeping March 1, 2004 Mackenzie CF. OR Peeping. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/or-peeping The Case A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete spontaneous abortion (miscarriage). At this community hospital, a new operating room (OR) su…

5549. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49631/psn-pdf
      July 01, 2011 - Patient Safety and Adherence to Self-Administered Medications July 1, 2011 Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications The Case A 30-year-o…

5550. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49487/psn-pdf
      August 21, 2005 - Surprise Wire August 21, 2005 Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/surprise-wire The Case A 39-year-old man with a history of liver disease presented to the emergency department (ED) with gastrointestinal bleeding and altered mental status. Due to his clinic…

5551. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49832/psn-pdf
      June 01, 2018 - Febrile Neutropenia and an Almost Fatal Medication Error June 1, 2018 Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error The Case A 33-year-old woman with recently diagnosed acute …

5552. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49791/psn-pdf
      April 01, 2017 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable April 1, 2017 Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable The Case An 84-year-old wo…

5553. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49650/psn-pdf
      March 01, 2012 - Turn the Other Cheek March 1, 2012 Starling J. Turn the Other Cheek. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/turn-other-cheek The Case A 56-year-old man underwent two skin biopsies to evaluate clinically concerning lesions. The first biopsy was diagnostic for squamous cell carcinoma (SCC) and docume…

5554. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
      March 01, 2009 - Spotlight Case July 2008 Spotlight Case All in the History Source and Credits This presentation is based on the February/March 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Christopher Fee, MD, University of California, San Francisco …

5555. Dual Therapy Debacle | PSNet
      psnet.ahrq.gov/web-mm/dual-therapy-debacle
      February 01, 2007 - Dual Therapy Debacle Citation Text: Kayser SR. Dual Therapy Debacle. 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 tagged PubMedId …

5556. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846922/psn-pdf
      March 29, 2023 - Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes March 29, 2023 https://psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions- and-improve-health Summary With increasing recognition that health is linked to the condit…

5557. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49649/psn-pdf
      March 01, 2012 - Cultural Dimensions of Depression March 1, 2012 Kinzie DJ. Cultural Dimensions of Depression. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/cultural-dimensions-depression The Case A 55-year-old Vietnamese man was admitted to a general medicine ward with vague complaints of inability to breathe and swallow…

5558. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850362/psn-pdf
      June 14, 2023 - Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital June 14, 2023 Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opp…

5559. Discharged Blindly | PSNet
      psnet.ahrq.gov/web-mm/discharged-blindly
      October 26, 2022 - Discharged Blindly Citation Text: Iezzoni LI. Discharged Blindly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…

5560. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience | PSNet
      psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
      December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005  View more articles from the same authors. Citation Text: Conway JB, Weingart SN. Organizational Change…