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Showing results for "failures".

  1. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
    June 01, 2013 - Spotlight Case July 2008 Spotlight Case Emergency Error 1 2 Source and Credits This presentation is based on the June 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London Editor, AHRQ WebM&M: Robe…

  2. Overriding Considerations | PSNet

    psnet.ahrq.gov/web-mm/overriding-considerations
    March 09, 2009 - Overriding Considerations Citation Text: Holtzman NA. Overriding Considerations. 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 tagg…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840255/psn-pdf
    November 16, 2022 - Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions November 16, 2022 Carayon P, Werner N, Makkenchery A, et al. Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions . PSNet [internet]. 2022. https://psnet.ahrq.gov/perspecti…

  4. A Picture Speaks 1000 Words | PSNet

    psnet.ahrq.gov/web-mm/picture-speaks-1000-words
    July 16, 2015 - A Picture Speaks 1000 Words Citation Text: Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …

  5. Medication Overdose | PSNet

    psnet.ahrq.gov/web-mm/medication-overdose
    September 01, 2011 - Medication Overdose Citation Text: Kaushal R. Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33701/psn-pdf
    October 01, 2010 - What Makes a Good Checklist October 1, 2010 McLaughlin AC. What Makes a Good Checklist. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/what-makes-good-checklist Perspective The use of checklists is a primitive yet remarkably effective strategy for ensuring accuracy in complex tasks. Checklists have lo…

  7. Listen to the Family | PSNet

    psnet.ahrq.gov/web-mm/listen-family
    April 15, 2015 - Listen to the Family Citation Text: Campbell D. Listen to the Family. 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…

  8. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.263_slideshow.ppt
    March 01, 2012 - Spotlight Case July 2008 Spotlight Case Postdischarge Follow-Up Phone Call * * Source and Credits This presentation is based on the March 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Michelle Mourad, MD, and Stephanie Rennke, MD; Divi…

  9. Toxic Tachycardia | PSNet

    psnet.ahrq.gov/web-mm/toxic-tachycardia
    March 01, 2005 - Toxic Tachycardia Citation Text: Wartofsky L. Toxic Tachycardia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  10. Hazards of Loading Doses | PSNet

    psnet.ahrq.gov/web-mm/hazards-loading-doses
    December 01, 2003 - Hazards of Loading Doses Citation Text: Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61080/psn-pdf
    October 28, 2020 - Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. October 28, 2020 DeLemos C. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49704/psn-pdf
    March 01, 2014 - Late Anemia Following Rh Disease in a Newborn March 1, 2014 Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn The Case A full-term neonate was delivered uneventfully to an Rh-negative woman who had re…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49494/psn-pdf
    January 01, 2006 - One Dose, Fifty Pills November 1, 2005 Smith L. One Dose, Fifty Pills . PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/one-dose-fifty-pills The Case A middle-aged man was admitted to the medical service of a teaching hospital with suspected vasculitis. When the initial diagnostic studies failed to provide …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49533/psn-pdf
    March 01, 2007 - Staggered Sensitivity Results March 1, 2007 Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/staggered-sensitivity-results The Case A 60-year-old woman with squamous cell carcinoma of the glottis underwent laryngectomy, anterior neck dissection, and pectoralis fla…

  15. Comanagement: Who's in Charge? | PSNet

    psnet.ahrq.gov/web-mm/comanagement-whos-charge
    July 01, 2011 - Comanagement: Who's in Charge? Citation Text: Cheng HQ. Comanagement: Who's in Charge?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…

  16. DNR in the OR and Afterwards | PSNet

    psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
    July 01, 2003 - DNR in the OR and Afterwards Citation Text: Lo B. DNR in the OR and Afterwards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49831/psn-pdf
    June 01, 2018 - Chest Pain in a Rural Hospital June 1, 2018 MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/chest-pain-rural-hospital Case Objectives Recognize that a significant proportion of the Unites States population receives care in rural safety net emergency dep…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60610/psn-pdf
    June 24, 2020 - Endometriosis: A Common and Commonly Missed and Delayed Diagnosis June 24, 2020 Mackenzie M, Royce C. Endometriosis: A Common and Commonly Missed and Delayed Diagnosis. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/endometriosis-common-and-commonly-missed-and-delayed-diagnosis   The Case A 15-year-old g…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846564/psn-pdf
    March 29, 2023 - Technology as a Tool for Improving Patient Safety March 29, 2023 Holmgren AJ, McBride S, Gale B, et al. Technology as a Tool for Improving Patient Safety . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety Introduction  In the past several decades, technological a…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849679/psn-pdf
    June 28, 2023 - Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture June 28, 2023 Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/under-pressure-tracheost…
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