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Showing results for "failures".

7041. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
      January 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case January 2008 How Do Providers Recover from Errors? Source and Credits This presentation is based on the January 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Colin P. West, MD, PhD, Mayo Clini…

7042. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49397/psn-pdf
      May 01, 2003 - The Dropped Lung May 1, 2003 Heffner JR. The Dropped Lung. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dropped-lung The Case A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…

7043. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49837/psn-pdf
      August 01, 2018 - Abdominal Aortic Aneurysm Screening August 1, 2018 Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening Case Objectives Describe risk factors associated with abdominal aortic aneurysm. Identify patient populations meeting criteria fo…

7044. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-473
      March 25, 2025 - March 5, 2025 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, …

7045. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49739/psn-pdf
      August 21, 2015 - Breathe Easy: Safe Tracheostomy Management August 21, 2015 Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management The Case A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumo…

7046. Transition to Nowhere | PSNet
      psnet.ahrq.gov/web-mm/transition-nowhere
      March 21, 2009 - Transition to Nowhere Citation Text: Farrell TW. Transition to Nowhere. 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 PubMed…

7047. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. | PSNet
      psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-errors-operating-room
      January 29, 2021 - Is that solution for IV or irrigation?: Fluid administration errors in the operating room. Citation Text: Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…

7048. Lethal Vertigo | PSNet
      psnet.ahrq.gov/web-mm/lethal-vertigo
      September 20, 2011 - Lethal Vertigo Citation Text: Furman JM. Lethal Vertigo. 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 …

7049. Turn the Other Cheek | PSNet
      psnet.ahrq.gov/web-mm/turn-other-cheek
      October 26, 2010 - Turn the Other Cheek Citation Text: Starling J. Turn the Other Cheek. 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 Endnote tagged PubMedId…

7050. Collegiality vs. Competence | PSNet
      psnet.ahrq.gov/web-mm/collegiality-vs-competence
      August 28, 2024 - Collegiality vs. Competence Citation Text: Sagin T. Collegiality vs. Competence. 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 tagg…

7051. Saved by ECMO | PSNet
      psnet.ahrq.gov/web-mm/saved-ecmo
      May 05, 2017 - Saved by ECMO Citation Text: Weiss NA. Saved by ECMO . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

7052. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33562/psn-pdf
      September 15, 2024 - Rapid Response Systems September 15, 2024 Rapid Response Systems. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/rapid-response-systems PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field.…

7053. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. | PSNet
      psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
      August 14, 2024 - SPOTLIGHT CASE Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. Citation Text: Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…

7054. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture | PSNet
      psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
      March 15, 2023 - SPOTLIGHT CASE Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture Citation Text: Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.. PSNet [internet]. Rockville (MD): Agency fo…

7055. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49714/psn-pdf
      August 21, 2014 - Pitfalls in Diagnosing Necrotizing Fasciitis August 21, 2014 Goh T, Goh LG. Pitfalls in Diagnosing Necrotizing Fasciitis. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis Case Objectives State the epidemiology of necrotizing fasciitis. Appreciate the high mortality a…

7056. In Conversation With… Vineet Arora, MD, MAPP | PSNet
      psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
      May 31, 2023 - In Conversation With… Vineet Arora, MD, MAPP September 1, 2015  Citation Text: In Conversation With… Vineet Arora, MD, MAPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citatio…

7057. The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department | PSNet
      psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely-intensive-care
      October 30, 2024 - The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …

7058. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836892/psn-pdf
      April 07, 2022 - The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department April 7, 2022 https://psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely- intensive-care Summary An increasing volume…

7059. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49537/psn-pdf
      June 01, 2007 - Beeline to Spine June 1, 2007 Smetana GW. Beeline to Spine. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/beeline-spine Case Objectives Understand the elements of preoperative medical evaluation. Appreciate the limited role for preoperative laboratory testing. Appreciate the importance of communication a…

7060. Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
      January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx Spotlight Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes Source and Credits • This presentation is based on the April 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/we…