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Showing results for "failures".

  1. Patient Safety in Office-Based Care Settings | PSNet

    psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
    January 31, 2024 - Clinician-reported non-routine events included case delays from machine failures and staffing issues.

  2. Safety Culture in EMS | PSNet

    psnet.ahrq.gov/perspective/safety-culture-ems
    May 26, 2021 - Perspectives on Safety Annual Perspective Impact of System Failures

  3. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
    January 01, 2021 - Spotlight Spotlight Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations Source and Credits • This presentation is based on the September 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary …

  4. Strengthening the Business Case for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
    May 01, 2013 - Strengthening the Business Case for Patient Safety Peter K. Lindenauer, MD, MSc | May 1, 2013  Also Read a Conversation View more articles from the same authors. Citation Text: Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. …

  5. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations | PSNet

    psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
    October 27, 2022 - SPOTLIGHT CASE Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations Citation Text: Tan F, Johl K, Kotova M. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations. PSNet [internet]. Rockville (MD): Agency for He…

  6. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis | PSNet

    psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
    March 09, 2022 - SPOTLIGHT CASE Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis Citation Text: Castillo JA, Price R, Kim KD. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis. PSNet [internet]. …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49619/psn-pdf
    February 01, 2011 - Paradoxical Pulse February 1, 2011 Roy CL. Paradoxical Pulse. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/paradoxical-pulse The Case An 80-year-old man with paroxysmal atrial fibrillation and symptomatic bradycardia underwent successful pacemaker placement as an outpatient. The patient was restarted on …

  8. Double Dose at Transfer | PSNet

    psnet.ahrq.gov/web-mm/double-dose-transfer
    November 01, 2012 - Double Dose at Transfer Citation Text: Hackman JL. Double Dose at Transfer. 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 Pu…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49824/psn-pdf
    March 01, 2018 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay March 1, 2018 O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay The Case A 35-year-old woman with no prior cardiac history calle…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49503/psn-pdf
    February 01, 2006 - Workaround Error February 1, 2006 Pape T. Workaround Error. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/workaround-error The Case A retired 81-year-old physician with metastatic colon cancer was admitted to an acute care hospital with pneumonia and congestive heart failure (CHF). After his acute hospita…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73146/psn-pdf
    April 28, 2021 - Patient Safety in Home Dialysis April 28, 2021 Morfín JA, Fitall E, Hall KK, et al. Patient Safety in Home Dialysis. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/patient-safety-home-dialysis Dialysis Care and Patient Safety Concerns In patients with chronic kidney disease, kidney function declines ov…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50697/psn-pdf
    November 27, 2019 - Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation November 27, 2019 Kulig CE, Ebong IA. Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/cardiac-arrest-woman-uti-case-qt-prolongation The Case A 36-year-old woman with a history of dep…

  13. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
    August 01, 2009 - Spotlight Case July 2008 Spotlight Case Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care * Source and Credits This presentation is based on the August 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME/CEU credit is available Commentary by: …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49448/psn-pdf
    June 01, 2004 - Listen to the Family June 1, 2004 Campbell D. Listen to the Family. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/listen-family The Case Vascular surgery was consulted for placement of a dialysis catheter in a patient on the medical floor. The surgical resident examined the patient, an elderly woman with …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49598/psn-pdf
    February 01, 2010 - Medication Reconciliation Pitfalls February 1, 2010 Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls The Case A 90-year-old woman who lived alone suffered a mechanical fall with subsequent hip fracture and was brought to the eme…

  16. Charcoal Lavage of the Lungs | PSNet

    psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
    January 01, 2016 - Charcoal Lavage of the Lungs Citation Text: Wigton RS. Charcoal Lavage of the Lungs. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49656/psn-pdf
    June 01, 2012 - Comanagement: Who's in Charge? June 1, 2012 Cheng HQ. Comanagement: Who's in Charge? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/comanagement-whos-charge The Case A 77-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with a left hip fracture to the orthopedic surg…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49716/psn-pdf
    August 21, 2014 - Benefits vs. Risks of Intraosseous Vascular Access August 21, 2014 Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access The Case A 72-year-old woman with a history of asthma, congestive heart…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60169/psn-pdf
    March 25, 2020 - Is that solution for IV or irrigation?: Fluid administration errors in the operating room. March 25, 2020 Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-erro…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49842/psn-pdf
    September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment September 1, 2018 Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment The Case As part of…
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