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Showing results for "failures".

7561. Lost in Sign Out and Documentation | PSNet
      psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
      January 31, 2011 - Lost in Sign Out and Documentation Citation Text: Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

7562. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
      January 01, 2022 - Spotlight Spotlight False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy Source and Credits • This presentation is based on the September 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by:…

7563. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33743/psn-pdf
      December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit December 1, 2012 Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit. PSNet [internet]. 2012. https://psnet.ahrq.gov…

7564. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49787/psn-pdf
      March 01, 2017 - Diagnosing a Missed Diagnosis March 1, 2017 Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis The Case A 57-year old woman was admitted to the hospital with cough, slurred speech, confusion, and disorientation. She was taking mod…

7565. Wandering Off the Floors: Safety and Security Risks of Patient Wandering | PSNet
      psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
      August 21, 2007 - SPOTLIGHT CASE Wandering Off the Floors: Safety and Security Risks of Patient Wandering Citation Text: Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Huma…

7566. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33683/psn-pdf
      April 01, 2009 - Accreditation and Regulation: Can They Help Improve Patient Safety? April 1, 2009 Warburton RN. Accreditation and Regulation: Can They Help Improve Patient Safety? PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety Perspective My grandfath…

7567. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33656/psn-pdf
      September 01, 2007 - In Conversation with...Atul Gawande, MD, MA, MPH September 1, 2007 In Conversation with..Atul Gawande, MD, MA, MPH. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph Editor's Note: Atul Gawande, MD, MA, MPH, Associate Professor of Surgery at Harvard Medical School a…

7568. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33614/psn-pdf
      June 01, 2005 - Interpreting the Patient Safety Literature June 1, 2005 Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/interpreting-patient-safety-literature Perspective Five years ago, a widely publicized randomized trial reported a 90% reduction in the inciden…

7569. A Mistaken Dose of Naloxone  | PSNet
      psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
      March 21, 2009 - A Mistaken Dose of Naloxone  Citation Text: Cutler E, Gunawardena D. A Mistaken Dose of Naloxone . 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 …

7570. Discharge Against Medical Advice | PSNet
      psnet.ahrq.gov/web-mm/discharge-against-medical-advice
      July 01, 2017 - Discharge Against Medical Advice Citation Text: Hwang SW. Discharge Against Medical Advice. 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 E…

7571. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49754/psn-pdf
      February 01, 2016 - Picking Up the Cause of the Stroke February 1, 2016 Chopra V. Picking Up the Cause of the Stroke. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/picking-cause-stroke The Case A 62-year-old man with poorly controlled diabetes was transferred to a tertiary care center from a community hospital for management…

7572. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33672/psn-pdf
      September 01, 2008 - In Conversation with…Eric G. Poon, MD, MPH September 1, 2008 In Conversation with…Eric G. Poon, MD, MPH. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph Editor's note: Eric G. Poon, MD, MPH, is Director of Clinical Informatics at Brigham and Women's Hospital and Assi…

7573. Too Much, Too Fast | PSNet
      psnet.ahrq.gov/web-mm/too-much-too-fast
      June 14, 2019 - Too Much, Too Fast Citation Text: Tuot D. Too Much, Too Fast. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

7574. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33605/psn-pdf
      March 12, 2021 - Medication Administration Errors March 12, 2021 MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. 2021. https://psnet.ahrq.gov/primer/medication-administration-errors Updated in March 2021. Originally published in January 2018 by researchers at the University of California, San Fra…

7575. Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration | PSNet
      psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
      October 30, 2024 - Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL June 14, 2023 Innov…

7576. Sick and Pregnant | PSNet
      psnet.ahrq.gov/web-mm/sick-and-pregnant
      August 25, 2021 - Sick and Pregnant Citation Text: El-Ibiary S. Sick and Pregnant. 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 Endnote tagged PubMedId RIS …

7577. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules | PSNet
      psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
      March 25, 2020 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules Citation Text: Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…

7578. 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 | PSNet
      psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
      February 26, 2025 - 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 Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Cop…

7579. Two Wrongs Don't Make a Right (Kidney) | PSNet
      psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
      April 01, 2010 - SPOTLIGHT CASE Two Wrongs Don't Make a Right (Kidney) Citation Text: DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Schola…

7580. The Wrongful Resuscitation | PSNet
      psnet.ahrq.gov/web-mm/wrongful-resuscitation
      October 12, 2012 - The Wrongful Resuscitation Citation Text: Teno JM. The Wrongful Resuscitation. 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 Endnote tagged…