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Showing results for "failures".

5821. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. | PSNet
      psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
      October 31, 2023 - SPOTLIGHT CASE Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. Citation Text: Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…

5822. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843234/psn-pdf
      January 01, 2013 - Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. February 1, 2023 Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive D…

5823. Miscommunication During the Interhospital Transport of a Critically Ill Child | PSNet
      psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
      March 27, 2024 - Miscommunication During the Interhospital Transport of a Critically Ill Child Citation Text: Rosenthal J, Hamline M. Miscommunication During the Interhospital Transport of a Critically Ill Child. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human …

5824. Maskedstats Nrd 2015Q4 Severity (pdf file)
      hcup-us.ahrq.gov/db/nation/nrd/stats/MaskedStats_NRD_2015Q4_Severity.PDF
      October 31, 2017 - please refer to the section on Description of Data Elements. For more information about the coding of HCUP data elements, HCUP Summary Statistics Report: NRD 2015 Q4 Severity File 07:12 Tuesday, October 31, 2017 1 Means of Continuous Data Elements please refer to the section on Description of Data Elements. For mor…

5825. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848109/psn-pdf
      April 26, 2023 - this process is called infiltration; when it is a vesicant medication, it is called extravasation.8 Failures

5826. Crossed Coverage | PSNet
      psnet.ahrq.gov/web-mm/crossed-coverage
      September 01, 2015 - and directed to a dedicated anticoagulation pharmacist, and it works well.( 11 ) Overall, multiple failures

5827. Pathologic Mistake | PSNet
      psnet.ahrq.gov/web-mm/pathologic-mistake
      February 15, 2010 - Latent errors also include insufficiently redundant system checks, and failures in preanalytic (e.g.,

5828. Preventable Rash | PSNet
      psnet.ahrq.gov/web-mm/preventable-rash
      October 01, 2012 - Reporting This case also involves a reportable disease, and therefore demonstrates one or more possible failures

5829. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72834/psn-pdf
      March 10, 2021 - burden of gathering key diagnostic information, technical problems, data entry problems, and system failures

5830. "Recurrent" Appendicitis | PSNet
      psnet.ahrq.gov/web-mm/recurrent-appendicitis
      January 15, 2020 - operations but often under extenuating circumstances, such as complicated patient factors (61%) or systems failures

5831. Departure From Central Line Ritual | PSNet
      psnet.ahrq.gov/web-mm/departure-central-line-ritual
      October 13, 2018 - 28, 2010 Profiles in patient safety: misplaced femoral line guidewire and multiple failures

5832. Fire in the Hole!—An OR Fire | PSNet
      psnet.ahrq.gov/web-mm/fire-hole-or-fire
      August 03, 2017 - August 3, 2017 Communication failures contributing to patient injury in anaesthesia malpractice

5833. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability | PSNet
      psnet.ahrq.gov/web-mm/mitigating-risk-intrahospital-transport-pediatric-patients-risk-physiologic-instability
      May 27, 2020 - A systematic review of failures in handoff communication during intrahospital transfers. 

5834. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
      June 01, 2012 - the transfer of patients between hospitals Efficiency of the transfer Technical problems (equipment failures

5835. The Wrong Channel | PSNet
      psnet.ahrq.gov/web-mm/wrong-channel
      February 01, 2003 - violations.( 3 ) The authors’ detailed analysis pointed to “inadequate use of technology” and “design failures

5836. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/104-what-are-4-es.pptx
      April 01, 2025 - 12 Engage: Identify Causes Determine the root causes of the failures in care.

5837. TeamSTEPPS® Diagnosis Improvement: Module 2 Diagnostic Team Structure
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module2-team-structure.pptx
      January 12, 2022 - Facilitating teamwork among these individuals is critical to avoiding the failures in the healthcare

5838. TeamSTEPPS® Diagnosis Improvement: Module 2 Diagnostic Team Structure (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module2-presenters-notes.pdf
      January 12, 2022 - Facilitating teamwork among these individuals is critical to avoiding the failures in the healthcare

5839. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49582/psn-pdf
      April 01, 2009 - period.(9) Among approximately 1650 PICCs, the most common complications were mechanical and accidental failures

5840. Observational Audits (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/observational-audits.pdf
      March 01, 2021 - Auditing allows you to obtain accurate compliance rates and identify process failures, such as a step