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Showing results for "failures".

7081. One Dose, Fifty Pills | PSNet
      psnet.ahrq.gov/web-mm/one-dose-fifty-pills
      January 13, 2021 - One Dose, Fifty Pills Citation Text: Smith L. One Dose, Fifty Pills . 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 PubMe…

7082. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49593/psn-pdf
      October 01, 2009 - Who Nose Where the Airway Is? October 1, 2009 Lee CR. Who Nose Where the Airway Is? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/who-nose-where-airway The Case A 70-year-old man with peripheral vascular disease was brought to the operating room to undergo vascular bypass surgery on his right upper extrem…

7083. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49489/psn-pdf
      September 01, 2005 - Double Trouble September 1, 2005 Gurwitz JH. Double Trouble. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/double-trouble Case Objectives Appreciate the incidence of adverse drug events in older persons List preventative measures that can be used to minimize medication errors in this population Encourage…

7084. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49662/psn-pdf
      August 01, 2012 - Wrong Turn through Colon: Misplaced PEG August 1, 2012 Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg The Case An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…

7085. A Costly Colonoscopy Leads to a Delay in Diagnosis | PSNet
      psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
      September 01, 2014 - A Costly Colonoscopy Leads to a Delay in Diagnosis Citation Text: Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar…

7086. Medication Reconciliation Victory After an Avoidable Error | PSNet
      psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error
      April 01, 2015 - Medication Reconciliation Victory After an Avoidable Error Citation Text: Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: …

7087. Glucose Roller Coaster | PSNet
      psnet.ahrq.gov/web-mm/glucose-roller-coaster
      February 02, 2022 - Glucose Roller Coaster Citation Text: Sharpe B. Glucose Roller Coaster. 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 PubMed…

7088. Triage Time Bomb | PSNet
      psnet.ahrq.gov/web-mm/triage-time-bomb
      September 01, 2008 - Triage Time Bomb Citation Text: Washington DL. Triage Time Bomb. 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 …

7089. In Conversation With… Sharon K. Inouye, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
      December 01, 2012 - In Conversation With… Sharon K. Inouye, MD, MPH December 1, 2012  Also Read an Essay Citation Text: In Conversation With… Sharon K. Inouye, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…

7090. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations | PSNet
      psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
      September 27, 2023 - SPOTLIGHT CASE Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations Citation Text: Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. PSNet [internet]. Agency for Healthcare Research and Qu…

7091. In Conversation with...Dean Schillinger, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md
      March 01, 2009 - to be the public hospital patient, because this patient would never have spoken up to overcome the failures

7092. Rapid Response Teams: Lessons from the Early Experience | PSNet
      psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
      November 01, 2005 - is a value, but means here not honesty in the ethical sense, but we mean we want to tell about our failures

7093. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.110_slideshow.ppt
      December 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case December 2005 Low on the Totem Pole Source and Credits This presentation is based on the Dec. 2005 Spotlight Case in Surgery/Anesthesia See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Robert Wachter, MD, …

7094. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.76_slideshow.ppt
      October 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case October 2004 Thin Air Source and Credits This presentation is based on the Oct. 2004 AHRQ WebM&M Spotlight Case in Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: David M. Gaba, MD, Stanford Univer…

7095. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33787/psn-pdf
      January 01, 2018 - Those failures then add up.

7096. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843150/psn-pdf
      December 05, 2022 - often hold a lot of tension in our bodies when we are uncomfortable, whether it is because of our own failures

7097. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. | PSNet
      psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
      November 25, 2020 - alarm-related sentinel events including alarm fatigue (most common), as well as equipment malfunctions/failures

7098. Spotlight: Mistaken Attribution, Diagnostic Misstep | PSNet
      psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
      July 01, 2011 - SPOTLIGHT CASE Spotlight: Mistaken Attribution, Diagnostic Misstep Citation Text: Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citat…

7099. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet
      psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
      March 25, 2020 - SPOTLIGHT CASE Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Citation Text: Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…

7100. Poorly Advanced Directives | PSNet
      psnet.ahrq.gov/web-mm/poorly-advanced-directives
      August 01, 2018 - Poorly Advanced Directives Citation Text: Anderson WG. Poorly Advanced Directives. 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 ta…