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Showing results for "failures".

6501. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49500/psn-pdf
      January 01, 2006 - Confusion With Acetaminophen January 1, 2006 Heubi JE. Confusion With Acetaminophen. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/confusion-acetaminophen The Case Parents brought their 5-year-old son to the emergency department (ED) with a 24-hour history of fever, cough, and frontal headache. Physical e…

6502. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33713/psn-pdf
      June 01, 2011 - The Safety of Medical Devices June 1, 2011 Nemeth CP. The Safety of Medical Devices. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/safety-medical-devices Perspective Edward Tenner is right. Technology does have reverberations, including unintended consequences, or "revenge effects."(1) While such dra…

6503. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49412/psn-pdf
      September 01, 2003 - Shake Well September 1, 2003 Flynn EA. Shake Well. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/shake-well The Case A 35-year-old patient on the neurology service was receiving carbamazepine for a seizure disorder. Daily serum drug levels consistently fell below the therapeutic range, which led the physi…

6504. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49647/psn-pdf
      February 01, 2012 - Amended Lab Results: Communication Slip February 1, 2012 Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip The Case A 25-year-old woman in her first pregnancy was seen at 33 weeks' gestation with new onset hypertension an…

6505. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49692/psn-pdf
      September 01, 2013 - A Picture Speaks 1000 Words September 1, 2013 Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/picture-speaks-1000-words The Case A 62-year-old man with a past medical history of hypertension, hyperlipidemia, and type A aortic dissection repair presented with chest p…

6506. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49689/psn-pdf
      August 21, 2013 - Anesthesia: A Weighty Issue August 21, 2013 Sinha AC. Anesthesia: A Weighty Issue. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/anesthesia-weighty-issue The Case A 77-year-old woman was evaluated preoperatively in anticipation of an elective left hip arthroplasty. She reported having a history of hyperte…

6507. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49511/psn-pdf
      May 01, 2006 - Citrate Mix-Up May 1, 2006 Weber RJ. Citrate Mix-Up. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/citrate-mix The Case A 36-year-old woman with multiple sclerosis, diabetes, and chronic renal failure was transferred from a skilled nursing facility (SNF) to the hospital for treatment of an infection. On a…

6508. Preface | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/preface.html
      March 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism Preface Previous Page Next Page Table of Contents Preventing Hospital-Associated Venous Thromboembolism Preface Executive Summary Chapter 1. The Framework for Improvement Chapter 2. Analyze Care Delivery Chapter 3. Outline the Evidence …

6509. HIT Readiness Instrument (xls file)
      digital.ahrq.gov/sites/default/files/docs/page/E-PrescribingPhysicianTool4.1.xlsx
      June 16, 2021 - HIT Readiness Instrument Introduction & Instructions Readiness Assessment for HIT[1] How do you know if your clinic is ready for an electronic health record or ePrescribing? Successful transition from paper-based charts to an e-prescribing system or electronic health record (EHR) requires organization-wide commi…

6510. Toolkit for Using the AHRQ Quality Indicators | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/qitool/index.html
      March 01, 2017 - Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety The Toolkit for Using the AHRQ Quality Indicators (QI Toolkit) is a free and easy-to-use resource for hospitals planning to use the AHRQ Quality Indicators (QIs), including the Patient Safety Indicators (PSIs), to track a…

6511. Alert Fatigue | PSNet
      psnet.ahrq.gov/primer/alert-fatigue
      March 15, 2025 - Alert Fatigue Citation Text: Alert Fatigue. 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 7 XML Endnote tagged PubMedId RIS Download Ci…

6512. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33585/psn-pdf
      March 15, 2025 - Radiation Safety March 15, 2025 Radiation Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/radiation-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in 2025…

6513. Advanced Methods in Delivery System Research - Planning, Executing, Analyzing, and Reporting Research on Delivery System Improvement | Agency for Healthcare Research and Quality
      www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/webinar04/formativeevalsl.html
      January 01, 2014 - Advanced Methods in Delivery System Research - Planning, Executing, Analyzing, and Reporting Research on Delivery System Improvement Webinar #4: Formative Evaluation (Slide Presentation) This slide presentation was presented at a webinar on July 15, 2013. Presenter: Jeffrey Smith, PhD(c) Discussant: Cheryl …

6514. Preface | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/vtguide/preface.html
      March 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism Preface Previous Page Next Page Table of Contents Preventing Hospital-Associated Venous Thromboembolism Preface Executive Summary Chapter 1. The Framework for Improvement Chapter 2. Analyze Care Delivery Chapter 3. Outline the Evidence …

6515. On-Time Preventable Hospital and Emergency Department Visits (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/2-preventablehospitalandedvisits-samplerpts_3.pdf
      November 30, 2013 - On-Time Preventable Hospital and Emergency Department Visits AHRQ’s Safety Program for Nursing Homes On-Time Preventable Hospital and Emergency Department Visits: Electronic Reports Five reports are described here. Each section presents a sample report followed by purpose, description, and users and potential u…

6516. Use of Observational Studies in Systematic Reviews of (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-guidance-observational-studies_methods.pdf
      June 01, 2010 - Use of Observational Studies in Systematic Reviews of Methods Guide for Comparative Effectiveness Reviews Selecting Observational Studies for Comparing Medical Interventions Comparative Effectiveness Reviews are systematic reviews of existing research on the effectiveness, comparative…

6517. Use of Observational Studies in Systematic Reviews of (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/methodsguidenorris_060420101.pdf
      June 01, 2010 - Use of Observational Studies in Systematic Reviews of Methods Guide for Comparative Effectiveness Reviews Selecting Observational Studies for Comparing Medical Interventions Comparative Effectiveness Reviews are systematic reviews of existing research on the effectiveness, comparative…

6518. Methods – Applying HCUP Quality Indicators (pdf file)
      hcup-us.ahrq.gov/reports/methods/2012_03.pdf
      January 01, 2012 - Methods – Applying HCUP Quality Indicators HCUP Methods Series kbr33831 Contact Information: Healthcare Cost and Utilization Project (HCUP) Agency for Healthcare Research and Quality 540 Gaither Road Rockville, MD 20850 http://www.hcup-us.ahrq.gov For Technical Assistance with HCUP Products: Em…

6519. Methods Applying AHRQ Quality Indicators to Healthcare Cost and Utilization Project (HCUP) Data for the Tenth (2012) NHQR and NHDR (pdf file)
      hcup-us.ahrq.gov/reports/methods/2012-02.pdf
      January 01, 2012 - Methods Applying AHRQ Quality Indicators to Healthcare Cost and Utilization Project (HCUP) Data for the Tenth (2012) NHQR and NHDR HCUP Methods Series kbr33831 Contact Information: Healthcare Cost and Utilization Project (HCUP) Agency for Healthcare Research and Quality 540 Gaither Road Rockville, MD 20…

6520. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
      www.ahrq.gov/sites/default/files/publications2/files/distributed-cognition-er-nurses_0.pdf
      August 01, 2022 - This case revealed numerous system failures that contributed to the initial misdiagnosis and needless … Communication failures: an insidious contributor to medi- cal mishaps.