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Total Results: 7,834 records

Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861760/psn-pdf
    January 31, 2024 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery January 31, 2024 Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837748/psn-pdf
    August 05, 2022 - Challenges of Diabetes Management and Medication Reconciliation August 5, 2022 Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation The Cases Case #1: A 53-year-old man …

  3. Patient as a Team Member in Clinical Care | PSNet

    psnet.ahrq.gov/curated-library/patient-team-member-clinical-care
    March 15, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Patient as a Team Member in Clinical Care  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybraria…

  4. Airway Obstruction during Anterior Cervical Spine Surgery | PSNet

    psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
    January 29, 2021 - Airway Obstruction during Anterior Cervical Spine Surgery Citation Text: Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: …

  5. An Incomplete Anesthesia History Leads to Adverse Outcomes | PSNet

    psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
    January 29, 2021 - An Incomplete Anesthesia History Leads to Adverse Outcomes Citation Text: Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: …

  6. Challenges of Diabetes Management and Medication Reconciliation | PSNet

    psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
    March 15, 2023 - Challenges of Diabetes Management and Medication Reconciliation Citation Text: Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation …

  7. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
    January 01, 2024 - Spotlight Spotlight Do Not Miss Sepsis Needles in Viral Haystacks! Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Michelle Hamline, MD, PhD, MAS and Ulfat Shaikh, MD, M…

  8. The PeaceHealth Governance Journey in Support of Quality and Safety | PSNet

    psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
    August 01, 2007 - The PeaceHealth Governance Journey in Support of Quality and Safety John L. Haughom, MD | August 1, 2007  Also Read a Conversation View more articles from the same authors. Citation Text: Haughom JL. The PeaceHealth Governance Journey in Support of Quality and …

  9. How Does Health Care Simulation Affect Patient Care? | PSNet

    psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
    August 01, 2018 - How Does Health Care Simulation Affect Patient Care? Joseph O. Lopreiato, MD, MPH | August 1, 2018  Also Read a Conversation View more articles from the same authors. Citation Text: Lopreiato JO. How Does Health Care Simulation Affect Patient Care?. PSNet [inter…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73334/psn-pdf
    August 01, 2024 - An Inadvertent Bolus of Norepinephrine. May 26, 2021 Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counc…

  11. Differences between professionals' views on patient safety culture in long-term and acute care? A cross-sectional study. | PSNet

    psnet.ahrq.gov/issue/differences-between-professionals-views-patient-safety-culture-long-term-and-acute-care-cross
    June 24, 2020 - Study Differences between professionals' views on patient safety culture in long-term and acute care? A cross-sectional study. Citation Text: Liukka M, Hupli M, Turunen H. Differences between professionals’ views on patient safety culture in long-term and acute care? A cross-sectional st…

  12. Feasibility of patient-reported diagnostic errors following emergency department discharge: a pilot study. | PSNet

    psnet.ahrq.gov/issue/feasibility-patient-reported-diagnostic-errors-following-emergency-department-discharge-pilot
    August 19, 2020 - Study Feasibility of patient-reported diagnostic errors following emergency department discharge: a pilot study. Citation Text: Gleason KT, Peterson SM, Dennison Himmelfarb CR, et al. Feasibility of patient-reported diagnostic errors following emergency department discharge: a pilot stud…

  13. Primary care–relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. | PSNet

    psnet.ahrq.gov/issue/primary-care-relevant-interventions-prevent-falling-older-adults-systematic-evidence-review
    May 27, 2020 - Review Primary care–relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Citation Text: Michael YL, Whitlock EP, Lin JS, et al. Primary care-relevant interventions to prevent falling in older adults: a syst…

  14. Effect of standardized handoff curriculum on improved clinician preparedness in the intensive care unit: a stepped-wedge cluster randomized clinical trial. | PSNet

    psnet.ahrq.gov/issue/effect-standardized-handoff-curriculum-improved-clinician-preparedness-intensive-care-unit
    October 19, 2022 - Study Classic Effect of standardized handoff curriculum on improved clinician preparedness in the intensive care unit: a stepped-wedge cluster randomized clinical trial. Citation Text: Parent B, LaGrone LN, Albirair MT, et al. Effect of Standardized Handoff Curr…

  15. Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. | PSNet

    psnet.ahrq.gov/issue/diagnostic-errors-intensive-care-unit-systematic-review-autopsy-studies
    March 10, 2021 - Review Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. Citation Text: Winters BD, Custer J, Galvagno SM, et al. Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. BMJ Qual Saf. 2012;21(11):894-902. doi:10.1136/bmj…

  16. How context affects electronic health record–based test result follow-up: a mixed-methods evaluation. | PSNet

    psnet.ahrq.gov/issue/how-context-affects-electronic-health-record-based-test-result-follow-mixed-methods
    April 04, 2011 - Study How context affects electronic health record–based test result follow-up: a mixed-methods evaluation. Citation Text: Menon S, Smith MW, Sittig DF, et al. How context affects electronic health record-based test result follow-up: a mixed-methods evaluation. BMJ Open. 2014;4(11):e0059…

  17. Impact of inpatient harms on hospital finances and patient clinical outcomes. | PSNet

    psnet.ahrq.gov/issue/impact-inpatient-harms-hospital-finances-and-patient-clinical-outcomes
    February 28, 2018 - Study Classic Impact of inpatient harms on hospital finances and patient clinical outcomes. Citation Text: Adler L, Yi D, Li M, et al. Impact of Inpatient Harms on Hospital Finances and Patient Clinical Outcomes. J Patient Saf. 2018;14(2):67-73. doi:10.1097/PTS.…

  18. Can patient safety incident reports be used to compare hospital safety? Results from a quantitative analysis of the English National Reporting and Learning System data. | PSNet

    psnet.ahrq.gov/issue/can-patient-safety-incident-reports-be-used-compare-hospital-safety-results-quantitative
    October 31, 2014 - Study Can patient safety incident reports be used to compare hospital safety? Results from a quantitative analysis of the English National Reporting and Learning System data. Citation Text: Howell A-M, Burns EM, Bouras G, et al. Can Patient Safety Incident Reports Be Used to Compare Hosp…

  19. 'Matching Michigan': a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. | PSNet

    psnet.ahrq.gov/issue/matching-michigan-2-year-stepped-interventional-programme-minimise-central-venous-catheter
    April 29, 2015 - Study 'Matching Michigan': a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. Citation Text: Bion J, Richardson A, Hibbert P, et al. 'Matching Michigan': a 2-year stepped interventional programme to …

  20. Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prevention and sepsis care. | PSNet

    psnet.ahrq.gov/issue/results-and-lessons-hospital-wide-initiative-incentivised-delivery-system-reform-improve
    March 02, 2022 - Study Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prevention and sepsis care. Citation Text: Sreeramoju P, Voy-Hatter K, White C, et al. Results and lessons from a hospital-wide initiative incentivised by delivery system…
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