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Showing results for "failures".

7341. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60328/psn-pdf
      May 27, 2020 - Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression May 27, 2020 Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory- …

7342. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. | PSNet
      psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
      July 08, 2022 - SPOTLIGHT CASE A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. Citation Text: Pasao K, Kashkouli P. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …

7343. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865373/psn-pdf
      March 27, 2024 - In Conversation with...Patrick Tighe about Artificial Intelligence March 27, 2024 Tighe P. In Conversation with..Patrick Tighe about Artificial Intelligence . PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence Editor's note: Patrick Tighe, MD, MS…

7344. In Conversation with…Carolyn Clancy, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
      September 01, 2005 - In Conversation with…Carolyn Clancy, MD September 1, 2005  Also Read an Essay Citation Text: In Conversation with…Carolyn Clancy, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. …

7345. Spotlight Case Hindsight Is 2020 Slides Final Revised 05.03.2024 (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
      January 01, 2024 - Spotlight Hindsight is 20/20: Thrombolytics for Alcohol Intoxication Source and Credits • This presentation is based on the April 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Eric Signoff, MD, Noelle Boctor, MD, and David K. B…

7346. In Conversation with… Edward Tenner, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
      June 01, 2011 - In Conversation with… Edward Tenner, PhD June 1, 2011  Also Read an Essay Citation Text: In Conversation with… Edward Tenner, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Cop…

7347. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846171/psn-pdf
      July 26, 2022 - Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation March 15, 2023 Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/agitated-delirium-contributes…

7348. Missed Opportunities for Suicide Risk Assessment | PSNet
      psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
      September 27, 2023 - SPOTLIGHT CASE Missed Opportunities for Suicide Risk Assessment Citation Text: Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation For…

7349. A Loss of Trust and a Missed Diagnosis | PSNet
      psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
      October 31, 2023 - SPOTLIGHT CASE A Loss of Trust and a Missed Diagnosis Citation Text: Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format:…

7350. In Conversation with...Richard Ricciardi about Office-Based Patient Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-patient-safety
      January 31, 2024 - Clinician-reported non-routine events included case delays from machine failures and staffing issues.

7351. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety | PSNet
      psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
      March 01, 2017 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety Sara J. Singer, MBA, PhD | September 1, 2013  View more articles from the same authors. Citation Text: Singer SJ. What We've Learned About Leveraging Leadership a…

7352. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience | PSNet
      psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
      July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience Karen Frush, MD | May 1, 2005  View more articles from the same authors. Citation Text: Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…

7353. Discharged Blindly | PSNet
      psnet.ahrq.gov/web-mm/discharged-blindly
      October 26, 2022 - Discharged Blindly Citation Text: Iezzoni LI. Discharged Blindly. 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 PubMedId RIS…

7354. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/857060/psn-pdf
      November 27, 2023 - The Role of Undergraduate Nursing Education in Patient Safety November 27, 2023 Stanley J, Gale B, Mossburg S. The Role of Undergraduate Nursing Education in Patient Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety Introduction Nurses are a li…

7355. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49812/psn-pdf
      November 01, 2017 - Specimen Almost Lost November 1, 2017 Hehe YK. Specimen Almost Lost. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/specimen-almost-lost The Case A 29-year-old woman presented to the hospital with a rash that had spread across her legs and abdomen. She was admitted to the medicine service for further evalu…

7356. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33621/psn-pdf
      November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience November 1, 2005 Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience Perspective Health care organizations throughout the world have ide…

7357. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
      January 01, 2020 - PowerPoint Presentation Spotlight A ʺReflexiveʺ Diagnosis in Primary Care 1 This presentation is based on the April 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John Betjemann, MD, and S. Andrew Josephson, MD, University of California, San…

7358. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49740/psn-pdf
      August 21, 2015 - Baffled by Botulinum Toxin August 21, 2015 Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/baffled-botulinum-toxin The Case A 5-year-old boy with a history of transverse myelitis with resultant spasticity of both lower extremities, gait abnormalities, neurogeni…

7359. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49595/psn-pdf
      December 01, 2009 - "Superficial" Report Leads to "Deep" Problem December 1, 2009 Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem The Case A 35-year-old woman presented to the emergency department (ED) complaining of left foot and an…

7360. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.149_slideshow.ppt
      May 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case May 2007 Antiseizure Medication Disorder Source and Credits This presentation is based on the May 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Brian K. Alldredge, Pharm…