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Showing results for "gaps".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846126/psn-pdf
    March 09, 2023 - allow nurses to compound, education is required for the whole surgical team to address educational gaps

  2. WebM&M: Case Studies | PSNet

    psnet.ahrq.gov/webmm-case-studies
    March 25, 2025 - Interpretation Error (13) Radiograph Interpretation Error (22) Discontinuities, Gaps

  3. A Room Without Orders | PSNet

    psnet.ahrq.gov/web-mm/room-without-orders
    September 01, 2011 - unknown, below is a suggested list of communications that should occur with direct admissions to mitigate gaps

  4. Robotic Surgery: Risks vs. Rewards | PSNet

    psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
    October 31, 2023 - There are clearly gaps with the current FDA device tracking system, as many more robotic errors are experienced

  5. Ebola: Are We Ready? | PSNet

    psnet.ahrq.gov/web-mm/ebola-are-we-ready
    July 01, 2012 - Unusual circumstances like Ebola may be very helpful to reveal unrecognized or underappreciated gaps

  6. Syringe Swap During Regional Block: A Case of Medication Error and Recovery | PSNet

    psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
    July 22, 2020 - reliable approach for checking medications, insufficient differentiation of packaging, and communication gaps

  7. A Laceration that Needed a Proper Exam, Not an X-Ray | PSNet

    psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
    November 25, 2020 - Mistakes are errors in planning and can be attributed to gaps in knowledge, lack of skill and/or training

  8. Spotlight Nstemi (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-07/spotlight_nstemi.pdf
    January 01, 2020 - Spotlight The NSTEMI Curbside Consultation Source and Credits • This presentation is based on the July 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Amparo C. Villablanca, MD and Gordon Wong, MD MBA o AHRQ WebM&M Editors …

  9. Discharged with IV antibiotics: When issues arise, who manages the complications? | PSNet

    psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
    October 10, 2017 - SPOTLIGHT CASE Discharged with IV antibiotics: When issues arise, who manages the complications? Citation Text: Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49829/psn-pdf
    May 01, 2018 - Root Cause Analysis Gone Wrong May 1, 2018 Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney transplant. A suitabl…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33736/psn-pdf
    September 01, 2012 - In Conversation With… Jack Needleman, PhD September 1, 2012 In Conversation With… Jack Needleman, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-jack-needleman-phd Editor's note: Jack Needleman, PhD, is a Professor in the Department of Health Policy and Management at UCLA School of P…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33729/psn-pdf
    May 01, 2012 - The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety May 1, 2012 Sharek PJ. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-pa…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49712/psn-pdf
    June 01, 2014 - May I Have Another?—Medication Error June 1, 2014 Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error The Case A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a pharmacology-tra…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33668/psn-pdf
    May 01, 2008 - In Conversation with…David W. Bates, MD, MSc May 1, 2008 In Conversation with…David W. Bates, MD, MSc. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc Editor's note: Dr. David Bates is a Professor at Harvard Medical School, Medical Director of Clinical and Quality …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841139/psn-pdf
    December 14, 2022 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. December 14, 2022 Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. PSNet [internet]. 2022. https://psnet.ah…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867985/psn-pdf
    January 01, 2025 - Suicide Prevention March 25, 2025 Boudreaux E, Gale B, Mossburg SE. Suicide Prevention. PSNet [internet]. 20024. https://psnet.ahrq.gov/perspective/suicide-prevention Introduction Suicide is one of the leading causes of death in the United States, accounting for nearly 50,000 deaths in 2022, a 36% rise since 2000…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49558/psn-pdf
    April 01, 2008 - Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad April 1, 2008 Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad Case Objectives Understand the indications for antibiotic treatment in …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49819/psn-pdf
    February 01, 2018 - Signout Fallout February 1, 2018 Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/signout-fallout Case Objectives Understand the role of communication failures in medical errors and preventable adverse events. Review the evidence in support of handoff improvement pr…

  19. Complaints as Safety Surveillance | PSNet

    psnet.ahrq.gov/web-mm/complaints-safety-surveillance
    May 05, 2021 - Complaints as Safety Surveillance Citation Text: Morris JL, Bismark M. Complaints as Safety Surveillance. 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 E…

  20. Root Cause Analysis Gone Wrong | PSNet

    psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
    August 28, 2024 - Root Cause Analysis Gone Wrong Citation Text: Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. 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 XML E…
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