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Total Results: 1,692 records

Showing results for "happen".

1361. Wrong Turn through Colon: Misplaced PEG | PSNet
      psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
      May 01, 2017 - July 5, 2023 Prescribing errors in children: why they happen and how to prevent them.

1362. The Missing Suction Tip | PSNet
      psnet.ahrq.gov/web-mm/missing-suction-tip
      January 01, 2006 - Surgical tools left in five patients: UW surgeons take precautions to ensure it doesn’t happen again.

1363. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33621/psn-pdf
      November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience November 1, 2005 Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience Perspective Health care organizations throughout the world have ide…

1364. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49471/psn-pdf
      December 01, 2004 - Carpe Diem (Seize the Day) December 1, 2004 Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/carpe-diem-seize-day The Case A 53-year-old man presented for a new patient visit at a local medical clinic. He had several chronic medical conditions including hypertension, h…

1365. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49463/psn-pdf
      October 14, 2004 - Moved Too Soon October 1, 2004 Lindenauer PK. Moved Too Soon. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/moved-too-soon The Case A 67-year-old man was admitted to a general hospital ward after undergoing a laminectomy. Two hours after arriving, while the patient was still groggy from anesthesia, a nurs…

1366. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49405/psn-pdf
      June 01, 2003 - XL or Smaller? June 1, 2003 Kozer E. XL or Smaller? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/xl-or-smaller The Case With a history of hypertension and chronic renal failure secondary to hemolytic uremia syndrome at age 3, a 14-year-old boy presented to the emergency department with dehydration second…

1367. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49595/psn-pdf
      December 01, 2009 - "Superficial" Report Leads to "Deep" Problem December 1, 2009 Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem The Case A 35-year-old woman presented to the emergency department (ED) complaining of left foot and an…

1368. Spotlight (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.443_slideshow.ppt
      May 01, 2018 - Spotlight Spotlight Out of Sight, Out of Mind: Out-of-Office Test Result Management 1 Source and Credits This presentation is based on the May 2018 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Eric Poon, MD, MPH, Duke University School o…

1369. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49626/psn-pdf
      May 01, 2011 - Outbreak May 1, 2011 Rothman R, Stapleton S. Outbreak. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/outbreak The Case A 36-year-old healthy man developed an acute febrile illness associated with a vesicular rash. He presented to an urgent care clinic where he was diagnosed with varicella infection ("chic…

1370. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.173_slideshow.ppt
      April 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case April 2008 Antibiotics for URI/Sinusitis: A Simple Decision Gone Bad Source and Credits This presentation is based on the April 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Sumant Ranji, MD,…

1371. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33676/psn-pdf
      November 01, 2008 - In Conversation with…Sanjay Saint, MD, MPH November 1, 2008 In Conversation with…Sanjay Saint, MD, MPH. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph Editor's note: Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann Arbor VA …

1372. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49438/psn-pdf
      March 05, 2004 - OR Peeping March 1, 2004 Mackenzie CF. OR Peeping. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/or-peeping The Case A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete spontaneous abortion (miscarriage). At this community hospital, a new operating room (OR) su…

1373. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849660/psn-pdf
      May 31, 2023 - Strategies to Improve Organizational Health Literacy. May 31, 2023 Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy Background Health literacy is important at both the personal …

1374. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
      November 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case November 2006 Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality Source and Credits This presentation is based on the November 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is…

1375. Amended Lab Results: Communication Slip | PSNet
      psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
      September 26, 2012 - Amended Lab Results: Communication Slip Citation Text: Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

1376. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33689/psn-pdf
      October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety October 1, 2009 Wachter R. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety Perspective …

1377. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33773/psn-pdf
      September 01, 2014 - Overuse as a Patient Safety Problem September 1, 2014 Moriates C. Overuse as a Patient Safety Problem. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/overuse-patient-safety-problem Perspective Nearly half of primary care physicians in the United States believe that patients cared for in their own prac…

1378. Dual Therapy Debacle | PSNet
      psnet.ahrq.gov/web-mm/dual-therapy-debacle
      February 01, 2007 - Dual Therapy Debacle Citation Text: Kayser SR. Dual Therapy Debacle. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

1379. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33846/psn-pdf
      November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety November 1, 2017 Rozenblum R, Bates DW. The Role of Patient-facing Technologies to Empower Patients and Improve Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-imp…

1380. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842779/psn-pdf
      January 12, 2011 - Resilience Engineering in Practice: a Guidebook. January 12, 2011 Hollnagel E, Parie?s J, Woods DD et al eds. Farnham UK; Ashgate, 2011. ISBN: 9781472420749 https://psnet.ahrq.gov/issue/resilience-engineering-practice-guidebook Safety-critical industries rely on organizational aptitude to respond to disr…