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Showing results for "failures".

7441. Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
      January 01, 2020 - Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx Spotlight Premature Closure: Was it Just Syncope? Source and Credits • This presentation is based on the November 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit i…

7442. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33611/psn-pdf
      July 01, 2005 - In Conversation with…Christopher P. Landrigan, MD April 1, 2005 In Conversation with…Christopher P. Landrigan, MD. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md Editor's Note: In October 2004, in what immediately became a landmark paper in patient safety, Dr.…

7443. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49484/psn-pdf
      June 01, 2005 - Two Pills, Same Drug June 1, 2005 Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/two-pills-same-drug The Case A 34-year-old woman with AIDS developed a fever and hypotension due to suspected pneumonia. Her past medical history included several AIDS-related complica…

7444. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49710/psn-pdf
      May 01, 2014 - Discontinued Medications: Are They Really Discontinued? May 1, 2014 Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued? PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued The Case A 69-year-old man with a history of chronic atrial f…

7445. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33625/psn-pdf
      January 01, 2006 - Aviation Safety Methods: Quickly Adopted but Questions Remain January 1, 2006 Thomas EJ. Aviation Safety Methods: Quickly Adopted but Questions Remain. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain Perspective On August 2, 2005, Air France flig…

7446. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846125/psn-pdf
      March 15, 2023 - The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis March 15, 2023 https://psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels- and-effective Summary …

7447. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
      May 01, 2015 - PowerPoint Presentation Spotlight Errors in Sepsis Management This presentation is based on the May 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: David Shimabukuro, MD, University of California, San Francisco (UCSF) Editor, AHRQ WebM&M: Rober…

7448. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49713/psn-pdf
      June 01, 2014 - CVC Removal: A Procedure Like Any Other June 1, 2014 Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other The Case A 27-year-old man with a history of Behçet disease and recurrent liver abscesses was admitted to the hospital for a p…

7449. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33782/psn-pdf
      March 01, 2015 - Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? March 1, 2015 Scott IA. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program Perspective Much…

7450. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49517/psn-pdf
      August 01, 2006 - Miscalculated Risk August 1, 2006 Strassels SA. Miscalculated Risk. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/miscalculated-risk The Case A healthy 36-year-old man was admitted to a teaching hospital for acute low back strain after lifting his 2- week-old infant. He received Vicodin (hydrocodone and a…

7451. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.85_slideshow.ppt
      March 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case March 2005 The Hidden Mystery Source and Credits This presentation is based on the March 2005 AHRQ WebM&M Spotlight Case in Hospital Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Douglas D. Br…

7452. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49784/psn-pdf
      February 01, 2017 - Safeguarding Diagnostic Testing at the Point of Care February 1, 2017 Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care The Case A 23-year-old woman presented to the family medicine clinic for…

7453. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49436/psn-pdf
      February 26, 2004 - Transfusion "Slip" February 1, 2004 Kaplan HS. Transfusion "Slip". PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/transfusion-slip The Case A married couple, Mr. and Mrs. M, was brought to the emergency department (ED) of a Level 1 trauma center after a half-ton truck that had skidded out of control struck…

7454. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.88_slideshow.ppt
      March 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case March 2005 The Hidden Mystery Source and Credits This presentation is based on the March 2005 AHRQ WebM&M Spotlight Case in Hospital Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Douglas D. Br…

7455. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49736/psn-pdf
      June 01, 2015 - Inflicting Confusion June 1, 2015 Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/inflicting-confusion The Case A 26-year-old man with recently diagnosed Crohn disease presented to the emergency department with acute-onset abdominal pain, nausea, vomiting, an…

7456. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49637/psn-pdf
      October 01, 2011 - The Dropped "No" October 1, 2011 Johnson AJ. The Dropped "No". PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/dropped-no The Case A 62-year-old man with a history of cirrhosis was admitted with increasing abdominal girth and swelling in his legs. Because the leg swelling was somewhat more pronounced in his…

7457. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49711/psn-pdf
      June 01, 2014 - Wandering Off the Floors: Safety and Security Risks of Patient Wandering June 1, 2014 Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering Case Objectives Define patie…

7458. Missing ECG and Missed Diagnosis Lead to Dangerous Delay | PSNet
      psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
      March 01, 2015 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay Citation Text: O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: G…

7459. Paradoxical Pulse | PSNet
      psnet.ahrq.gov/web-mm/paradoxical-pulse
      May 01, 2013 - Paradoxical Pulse Citation Text: Roy CL. Paradoxical Pulse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

7460. Workaround Error | PSNet
      psnet.ahrq.gov/web-mm/workaround-error
      October 30, 2024 - Workaround Error Citation Text: Pape T. Workaround Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …