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Showing results for "failures".

7401. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33856/psn-pdf
      April 01, 2018 - Patient Safety During Hospital Discharge April 1, 2018 Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge Perspective Patients are admitted to the hospital in the United States 35 million times per year.(1)…

7402. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841493/psn-pdf
      December 14, 2022 - Telehealth and Patient Safety. December 14, 2022 O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/telehealth-and-patient-safety Background In recent years, telehealth, or the delivery of healthcare over a distance using telecommunications techno…

7403. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49751/psn-pdf
      January 01, 2016 - New Patient Mistakenly Checked in as Another January 1, 2016 Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another The Case A 55-year-old man, presented to a primary care physician's office for an initial vis…

7404. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49430/psn-pdf
      January 01, 2004 - Triage Time Bomb January 1, 2004 Washington DL. Triage Time Bomb. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/triage-time-bomb The Case A parent presented with a child to the emergency department (ED) triage area (located around the corner and down the hall from the actual ED). The child was febrile, an…

7405. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50843/psn-pdf
      January 29, 2020 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia January 29, 2020 Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia The Case A 54-year-old man was brought t…

7406. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.278_slideshow.ppt
      September 01, 2012 - Spotlight Case July 2008 Spotlight Case Peripheral IV in Too Long 1 2 Source and Credits This presentation is based on the September 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Chi-Tai Fang, MD, PhD; Associate Professor, National Taiwan Uni…

7407. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49427/psn-pdf
      January 01, 2004 - Inadvertent Castration January 1, 2004 Calland FJ. Inadvertent Castration. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/inadvertent-castration The Case An 83-year-old man presented with a left groin mass, "which had been there for years" but had recently increased in size. The patient described persisten…

7408. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49726/psn-pdf
      March 01, 2015 - Two Wrongs Don't Make a Right (Kidney) March 1, 2015 DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney Case Objectives Review the current definition of wrong-site surgery. Describe the incidence of wrong-site surgery, and the…

7409. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49756/psn-pdf
      April 01, 2016 - Lost in Sign Out and Documentation April 1, 2016 Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation The Case A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the emergency physician, …

7410. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865467/psn-pdf
      March 27, 2024 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences March 27, 2024 Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferenc…

7411. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49560/psn-pdf
      April 01, 2008 - The Wrongful Resuscitation April 1, 2008 Teno JM. The Wrongful Resuscitation. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/wrongful-resuscitation The Case   An 80-year-old man with diabetes, peripheral vascular disease, bilateral below-the-knee amputations, and poor quality of life had previously been r…

7412. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33658/psn-pdf
      October 01, 2007 - In Conversation with...David Marx, JD October 1, 2007 In Conversation with..David Marx, JD. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd Editor's Note: An engineer and an attorney by training, David Marx, JD, is president of Outcome Engineering, a risk management firm. …

7413. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49479/psn-pdf
      April 01, 2005 - The Forgotten Med April 1, 2005 Cucina R. The Forgotten Med. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/forgotten-med The Case A 78-year-old woman with a history of chronic obstructive pulmonary disease (COPD) came to the hospital with increasing shortness of breath and chest pain. Although she had no …

7414. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.158_slideshow.ppt
      September 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case September 2007 Medication Reconciliation: Whose Job Is It? Source and Credits This presentation is based on the September 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Eric G. Poon, MD, MPH, Ha…

7415. Wrong Route for Nutrients | PSNet
      psnet.ahrq.gov/web-mm/wrong-route-nutrients
      September 04, 2010 - Wrong Route for Nutrients Citation Text: Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…

7416. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49683/psn-pdf
      April 01, 2013 - Acute Care Admission of the Behavioral Health Patient April 1, 2013 Weiss AP, Rosenbaum JF. Acute Care Admission of the Behavioral Health Patient. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/acute-care-admission-behavioral-health-patient The Case A 25-year-old man presented to the emergency department (E…

7417. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49601/psn-pdf
      April 01, 2010 - Nosy Business April 1, 2010 Orlandi RR. Nosy Business. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/nosy-business The Case   A 59-year-old man with a history of idiopathic thrombocytopenic purpura (ITP) presented to the emergency department (ED) with epistaxis (a "nose bleed"). He reported no previous h…

7418. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49521/psn-pdf
      September 12, 2006 - A Troubling Amine September 1, 2006 Flynn EA. A Troubling Amine. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/troubling-amine The Case A 43-year-old woman was admitted to the intensive care unit for symptoms of heart and respiratory failure. She was found to have severe mitral and tricuspid valve regurgi…

7419. Misleading Complaint | PSNet
      psnet.ahrq.gov/web-mm/misleading-complaint
      December 01, 2009 - Misleading Complaint Citation Text: Soni K, Dhaliwal G. Misleading Complaint. 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 …

7420. Strategies to Improve Organizational Health Literacy. | PSNet
      psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
      August 30, 2023 - Strategies to Improve Organizational Health Literacy. Citation Text: Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format:…