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Total Results: 7,834 records

Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33777/psn-pdf
    January 01, 2015 - Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care January 1, 2015 Plsek PE. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49652/psn-pdf
    May 01, 2012 - Double Dose at Transfer May 1, 2012 Hackman JL. Double Dose at Transfer. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/double-dose-transfer The Case A 74-year-old man with history of diabetes and hypertension was admitted to the emergency department (ED) for left lower extremity pain, swelling, and erythe…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33586/psn-pdf
    December 15, 2024 - Alert Fatigue December 15, 2024 Alert Fatigue. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/alert-fatigue 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. Bac…

  4. Readmissions and Adverse Events After Discharge | PSNet

    psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
    April 27, 2022 - Readmissions and Adverse Events After Discharge Citation Text: Readmissions and Adverse Events After Discharge. 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…

  5. Falls | PSNet

    psnet.ahrq.gov/primer/falls
    October 27, 2021 - Falls Citation Text: Falls. 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 Download Citation …

  6. Safety and Medical Education | PSNet

    psnet.ahrq.gov/perspective/safety-and-medical-education
    December 01, 2013 - UME level, the Association of American Medical Colleges has defined the ability to "identify system failures

  7. In Conversation With...Donald A. Norman, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
    November 01, 2006 - January 5, 2017 Preventing adverse events caused by emergency electrical power system failures

  8. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? | PSNet

    psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
    September 01, 2006 - However, it will surely take time and patience, as these changes will bring as many failures as successes

  9. In Conversation With… David Blumenthal, MD, MPP | PSNet

    psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
    March 27, 2024 - more and more to consumer-mediated exchange as a way to get past those disincentives, those market failures

  10. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough | PSNet

    psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
    September 01, 2003 - like there is something still inside me. " The second case illustrates the consequences of process failures

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60721/psn-pdf
    July 21, 2020 - immediate attention, as well as ensuring there are options available to patients so that technical failures

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866578/psn-pdf
    August 28, 2024 - Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy August 28, 2024 Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insul…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865309/psn-pdf
    May 29, 2024 - A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care May 29, 2024 Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post- Tracheostomy Care. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-i…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49431/psn-pdf
    January 01, 2004 - Crushing Chest Pain: A Missed Opportunity January 1, 2004 Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity Case Objectives Appreciate the challenges of diagnosing aortic dissection Describe a Bayesian approach to dia…

  15. Consequences of Medical Overuse | PSNet

    psnet.ahrq.gov/web-mm/consequences-medical-overuse
    May 05, 2021 - SPOTLIGHT CASE Consequences of Medical Overuse Citation Text: Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibT…

  16. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
    January 01, 2020 - Spotlight Spotlight Fatal PCA Opioid-Induced Respiratory Depression Source and Credits • This presentation is based on the May 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP o Editors in Chie…

  17. Updates in the Management of High-Risk Pulmonary Embolism | PSNet

    psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
    December 02, 2020 - Updates in the Management of High-Risk Pulmonary Embolism Citation Text: Kabrhel C, Aaronson E. Updates in the Management of High-Risk Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Forma…

  18. Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities. | PSNet

    psnet.ahrq.gov/web-mm/challenging-case-multiple-suicide-attempts-complex-patient-psychiatric-comorbidities
    September 27, 2023 - SPOTLIGHT CASE Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities. Citation Text: Bourgeois JA, Xiong G. Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities.. PSNet [internet]. Rockville (MD): Agency for …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33855/psn-pdf
    April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM April 1, 2018 In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm Editor's note: Dr. Krumholz, Harold H. Hines, Jr. Professor of Medicine at the Yale School of Medicine and Directo…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49553/psn-pdf
    January 01, 2008 - Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures January 1, 2008 Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures The…
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