-
psnet.ahrq.gov/node/74121/psn-pdf
November 30, 2021 - The intravenous fluid was opened up as a bolus. The uterus was boggy on examination.
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psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
January 01, 2023 - for use of prophylactic anticoagulation unless she was
admitted to the antepartum service leading up
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psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
June 15, 2022 - Quality
April 26, 2023
WebM&M Cases
Coming up
-
psnet.ahrq.gov/node/49392/psn-pdf
April 01, 2003 - The following precautions were taken: Side rails up; Bed in
lowest possible position; Call light immediately
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psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
August 30, 2023 - agility and determination to lead, convene, identify, and conduct small tests of change and to ramp up … Hartford Foundation , we set up a rapid response network specific to nursing homes to offer brief calls … improvement, and it’s prompted a lot of important conversation that they may never have been addressed up
-
psnet.ahrq.gov/node/60611/psn-pdf
June 24, 2020 - Medical care is complex and best practices frequently change, making it difficult for providers to keep up
-
psnet.ahrq.gov/node/853902/psn-pdf
September 27, 2023 - cultural and language barriers with patients, communication barriers between doctors, and lack of
back-up
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - risk for OSA based on a score calculated from questions related to snoring, daytime fatigue, waking up
-
psnet.ahrq.gov/node/864867/psn-pdf
April 10, 2024 - examination, there was no facial droop, but facial symmetry
was difficult to assess as he would not follow
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psnet.ahrq.gov/web-mm/missed-pneumonia
June 01, 2005 - Although it is possible that the pleural fluid analysis might have facilitated the diagnosis of pneumonia, up … More
Related Resources
WebM&M Cases
Coming up
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psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
May 16, 2022 - decided that I wanted to turn EMS [emergency medical services] into my full-time career, and I ended up … NEMSIS has done a really good job at partnering with all of the vendors to come up with a suggested list … So we feel like it's really important to set up the baseline, because it's possible to improve that. … real-time information and more real-time alerting around patient safety events is going to start to pick up … So, I think that this progression is probably at a natural point, but it's picking up quickly, and I'm
-
psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
March 10, 2021 - quality information about my fall risk or I can work with my healthcare team to ensure that my visitors follow … LH : Exactly, and to leverage that as a strategy opens up so much potential in creating healthy communities … The ROI question, how soon does that come up? Are you going to just start doing this?
-
psnet.ahrq.gov/node/49714/psn-pdf
August 21, 2014 - While SSTIs account for up to 14 million outpatient visits in the
United States each year (4530 per … present with the greatest diagnostic
challenge are those who present with severe pain but without fever (up
-
psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
November 02, 2016 - many challenges remain in the inpatient safety field, AHRQ recognizes the need to examine and keep up … Cases
Tacit Handover, Overt Mishap
June 1, 2010
Speaking up
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - Over the next 48 hours he was given increasing doses of extended-release morphine (up to a dose of morphine … He was found to have new acute renal insufficiency, which likely had contributed to a build-up of opioids
-
psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
March 24, 2021 - While SSTIs account for up to 14 million outpatient visits in the United States each year (4530 per 100,000 … present with the greatest diagnostic challenge are those who present with severe pain but without fever (up
-
psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
July 02, 2019 - communications and reference material with a real-time reminder of the change to the order set that could pop up
-
psnet.ahrq.gov/web-mm/forgotten-med
July 01, 2006 - Epilogue
April 1, 2009
WebM&M Cases
Citrate Mix-Up
-
psnet.ahrq.gov/node/33709/psn-pdf
July 01, 2011 - patients' clinical course and condition, as well as what tasks need to be performed (e.g., following
up
-
psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
November 21, 2018 - Are specific resources needed, such as mock-up rooms or virtual tools, to integrate safety culture, process