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Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33793/psn-pdf
    November 01, 2015 - In Conversation With… Kaveh Shojania, MD November 1, 2015 In Conversation With… Kaveh Shojania, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md Editor's note: Kaveh Shojania, MD, is Editor-in-Chief of BMJ Quality and Safety and Director of the Centre for Quality Impro…

  2. Technology as a Tool for Improving Patient Safety | PSNet

    psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
    April 26, 2023 - Annual Perspective Technology as a Tool for Improving Patient Safety A Jay Holmgren, Susan McBride,Bryan Gale, Sarah Mossburg | March 29, 2023  View more articles from the same authors. Citation Text: Holmgren AJ, McBride S, Gale B, et al. Technology as a …

  3. The Lost Start Date: an Unknown Risk of E-prescribing | PSNet

    psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
    December 02, 2020 - SPOTLIGHT CASE The Lost Start Date: an Unknown Risk of E-prescribing Citation Text: Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cit…

  4. Patient Safety Events Involving Opioid Dose Stacking | PSNet

    psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
    July 08, 2022 - SPOTLIGHT CASE Patient Safety Events Involving Opioid Dose Stacking Citation Text: Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Cita…

  5. Another Fall | PSNet

    psnet.ahrq.gov/web-mm/another-fall
    June 01, 2010 - SPOTLIGHT CASE Another Fall Citation Text: Bogardus SG. Another Fall. 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 tagg…

  6. One Toxic Drug Is Not Like Another | PSNet

    psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
    October 02, 2019 - SPOTLIGHT CASE One Toxic Drug Is Not Like Another Citation Text: Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTe…

  7. When Patients and Providers Speak Different Languages | PSNet

    psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
    December 08, 2021 - SPOTLIGHT CASE When Patients and Providers Speak Different Languages Citation Text: Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation …

  8. The Weekend Effect in Cardiology: Is It Real? If So, Can It Be Fixed? | PSNet

    psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed
    June 01, 2017 - The Weekend Effect in Cardiology: Is It Real? If So, Can It Be Fixed? Vanessa K. Martin, DO, MS; Nasim Mirnateghi, PhD; and Mahdi Khoshchehreh, MD, MS | June 1, 2017  Also Read a Conversation View more articles from the same authors. Citation Text: Martin …

  9. Isolated Clot, Real Error | PSNet

    psnet.ahrq.gov/web-mm/isolated-clot-real-error
    December 01, 2013 - SPOTLIGHT CASE Isolated Clot, Real Error Citation Text: Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3…

  10. Hospital-Acquired Diabetic Ketoacidosis. | PSNet

    psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
    October 28, 2020 - Hospital-Acquired Diabetic Ketoacidosis. Citation Text: Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar Bi…

  11. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy | PSNet

    psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
    April 08, 2019 - SPOTLIGHT CASE The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy Citation Text: Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcar…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49392/psn-pdf
    April 01, 2003 - Another Fall April 1, 2003 Bogardus SG. Another Fall. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/another-fall Case Objectives List risk factors for falls in hospitalized patients Understand appropriate use of restraints Identify system issues contributing to falls in hospitalized patients Case & Comm…

  13. The Deadly Duo | PSNet

    psnet.ahrq.gov/web-mm/deadly-duo
    April 28, 2021 - The Deadly Duo Citation Text: Maldonado JR. The Deadly Duo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  14. Medication Handling and Compounding Errors in the Operating Room. | PSNet

    psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
    May 16, 2022 - Medication Handling and Compounding Errors in the Operating Room. Citation Text: Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…

  15. In Conversation With... Jeffrey Shuren, MD, JD | PSNet

    psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd
    May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD May 28, 2020  Also Read the Essay Citation Text: In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020.In Conversation With... Jeffrey Shuren, MD, JD. PSNet [internet]. Rockville (MD): Agency for Healt…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867653/psn-pdf
    February 26, 2025 - In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis February 26, 2025 Behrhorst J, Gale B, Van CM. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evoluti…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865466/psn-pdf
    March 27, 2024 - Equity in Patient Safety March 27, 2024 Thomas A, Lee M, Mossburg S. Equity in Patient Safety. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/equity-patient-safety Introduction Safety and equity are among the central components that determine quality of care, according to nonprofit advisory agencies l…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846975/psn-pdf
    March 28, 2023 - In Conversation with... Christie Allen about Maternal Safety and Perinatal Mental Health March 28, 2023 In Conversation with.. Christie Allen about Maternal Safety and Perinatal Mental Health. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-christie-allen-about-maternal-safety-and-perinatal…

  19. Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet) | PSNet

    psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet
    April 01, 2005 - Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet) Robert M. Wachter, MD | April 1, 2005  Also Read a Conversation View more articles from the same authors. Citation Text: Wachter R. Introducing the New AHRQ WebM&M and AHRQ Patient Safety Ne…

  20. In Conversation with…Christopher P. Landrigan, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
    April 01, 2005 - In Conversation with…Christopher P. Landrigan, MD April 1, 2005  Also Read an Essay Citation Text: In Conversation with…Christopher P. Landrigan, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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