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Total Results: 7,834 records

Showing results for "failures".

7201. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49774/psn-pdf
      November 01, 2016 - Don't Dismiss the Dangerous: Obstetric Hemorrhage November 1, 2016 Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage Case Objectives List the common causes of obstetric hemorrhage and the need for a unit-sta…

7202. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. | PSNet
      psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
      October 28, 2020 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. Citation Text: Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…

7203. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. | PSNet
      psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
      March 15, 2023 - SPOTLIGHT CASE False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. Citation Text: Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …

7204. Project BOOST Increases Patient Understanding of Treatment and Follow-up Care | PSNet
      psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
      February 26, 2025 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 26, 2021 Innovation Contact …

7205. A "Reflexive" Diagnosis in Primary Care | PSNet
      psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
      April 01, 2008 - SPOTLIGHT CASE A "Reflexive" Diagnosis in Primary Care Citation Text: Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: …

7206. Physical Diagnosis: A Lost Art? | PSNet
      psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
      January 17, 2018 - SPOTLIGHT CASE Physical Diagnosis: A Lost Art? Citation Text: Thompson GR, Verghese A. Physical Diagnosis: A Lost Art?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Schola…

7207. In Conversation with... Dr. Neal Sikka and Dr. Colton Hood about Remote Patient Monitoring | PSNet
      psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-patient-monitoring
      March 15, 2023 - In Conversation with... Dr. Neal Sikka and Dr. Colton Hood about Remote Patient Monitoring March 15, 2023  Also Read the Essay Citation Text: In Conversation with.. Dr. Neal Sikka and Dr. Colton Hood about Remote Patient Monitoring. PSNet [internet]. 2023.In Conve…

7208. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865296/psn-pdf
      March 27, 2024 - National Patient Safety Goals March 27, 2024 Shaikh U. National Patient Safety Goals. PSNet [internet]. 2024. https://psnet.ahrq.gov/primer/national-patient-safety-goals Background Despite the development and publication of effective and evidence-based strategies to enhance patient safety and reduce preventable h…

7209. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33616/psn-pdf
      August 01, 2005 - The Unfinished Patient Safety Agenda August 1, 2005 Aiken LH. The Unfinished Patient Safety Agenda. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda Perspective The goal set by the Institute of Medicine (IOM) in 1999 to reduce medical errors by half within 5 years has no…

7210. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33613/psn-pdf
      May 01, 2005 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience May 1, 2005 Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience Pe…

7211. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33571/psn-pdf
      March 15, 2025 - Reporting Patient Safety Events March 15, 2025 Reporting Patient Safety Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/reporting-patient-safety-events PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in th…

7212. Culture of Safety | PSNet
      psnet.ahrq.gov/primer/culture-safety
      September 15, 2024 - Culture of Safety Citation Text: Culture of Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Dow…

7213. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33561/psn-pdf
      September 15, 2024 - Never Events September 15, 2024 Never Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/never-events 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. Last reviewed in 2024. Backg…

7214. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866839/psn-pdf
      September 25, 2024 - Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations September 25, 2024 Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/errors-managing-open-wound-elb…

7215. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
      January 01, 2024 - Spotlight Spotlight Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations 1 Source and Credits This presentation is based on the September 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: David…

7216. No Blood, Please | PSNet
      psnet.ahrq.gov/web-mm/no-blood-please
      January 14, 2011 - No Blood, Please Citation Text: Liang BA. No Blood, Please. 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 …

7217. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851869/psn-pdf
      July 31, 2023 - Building Capacity for Patient Safety July 31, 2023 Hoffman R, Mossburg S, Van CM. Building Capacity for Patient Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/building-capacity-patient-safety In its 2019 report, Safer Together: A National Action Plan to Advance Patient Safety, the National Steer…

7218. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33871/psn-pdf
      December 22, 2018 - Maternal Safety December 22, 2018 Lyndon A. Maternal Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/maternal-safety Annual Perspective 2018 The Context of Maternal Safety Childbirth-related maternal health outcomes have been worsening for some time in the United States. After a dramatic reduc…

7219. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.185_slideshow.ppt
      October 01, 2008 - Spotlight Case July 2008 Spotlight Case Recurrent Hypoglycemia: A Care Transition Failure? * * Source and Credits This presentation is based on the October 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Ted Eytan, MD, MS, MPH Editor, …

7220. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.233_slideshow.ppt
      February 01, 2011 - Spotlight Case July 2008 Spotlight Case One Toxic Drug Is Not Like Another * * Source and Credits This presentation is based on the February 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Eric S. Holmboe, MD, American Board of Internal…