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Total Results: 1,692 records

Showing results for "happen".

  1. The Role of Graduate Medical Education (GME) in Improving Patient Safety | PSNet

    psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
    February 01, 2010 - sure that there is oversight of the patient care transitions, which currently does not necessarily happen … I am very hopeful that two other things will happen.

  2. In Conversation with…Thomas J. Nasca, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
    February 01, 2010 - sure that there is oversight of the patient care transitions, which currently does not necessarily happen … I am very hopeful that two other things will happen.

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33809/psn-pdf
    June 01, 2016 - When I think back to my days at AHRQ, we had a fantasy that something like this would begin to happen

  4. 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 - They need to be aware of what may happen and when to reach out to their physician or go to the emergency

  5. In Conversation With… Ann L. Hendrich, RN, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
    February 26, 2025 - on these high beds with a step stool beside it and that actually becomes like an accident waiting to happen

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33805/psn-pdf
    April 01, 2016 - to come together because of the other pressures in the environment, or CLER is actually making that happen

  7. The Hazards of Distraction: Ticking All the EHR Boxes | PSNet

    psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
    April 09, 2014 - How then did it happen, and what are the implications for the use of checklists and order sets in medicine

  8. Right? Left? Neither! | PSNet

    psnet.ahrq.gov/web-mm/right-left-neither
    November 16, 2022 - Performing an invasive procedure on the wrong patient should never happen.

  9. Anticoagulation: Held Too Long | PSNet

    psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
    April 01, 2008 - which can lead to transition errors (as in this case) and harm to patients (which, luckily, did not happen

  10. Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
    January 01, 2023 - • Before this could happen, the patient developed increasing hypoxemia and respiratory distress,

  11. Emergent Triage Miss | PSNet

    psnet.ahrq.gov/web-mm/emergent-triage-miss
    March 06, 2015 - well studied.( 4,20 ) This is only one of many reasons for under-triaging patients, which can still happen

  12. Retained Surgical Items: Definition and Epidemiology. | PSNet

    psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
    September 15, 2024 - generally considered to have experienced a “ never event ”, a safety event that is never supposed to happen

  13. The Safety and Quality of Long Term Care | PSNet

    psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
    January 01, 2016 - The Commentary This case highlights the reality that serious adverse events happen frequently in nursing

  14. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. | PSNet

    psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
    March 15, 2023 - post-procedural pneumothorax with CXR, interpretation and communication of the CXR results did not happen

  15. Deciphering the Code | PSNet

    psnet.ahrq.gov/web-mm/deciphering-code
    November 16, 2022 - Deciphering the Code Citation Text: Goldstein MK. Deciphering the Code. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50756/psn-pdf
    December 18, 2019 - A Mistaken Dose of Naloxone? December 18, 2019 Cutler E, Gunawardena D. A Mistaken Dose of Naloxone?. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/mistaken-dose-naloxone The Case A 55-year-old man with widely metastatic gastric cancer presented to his oncologist's office for a follow-up appointment. He h…

  17. Transfusion "Slip" | PSNet

    psnet.ahrq.gov/web-mm/transfusion-slip
    June 14, 2011 - Transfusion "Slip" Citation Text: Kaplan HS. Transfusion "Slip". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49638/psn-pdf
    January 01, 2012 - Communication Failure—Who's in Charge? October 1, 2011 Fackler J, Schwartz JM. Communication Failure—Who's in Charge? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/communication-failure-whos-charge The Case A 20-month-old boy was admitted to the intensive care unit (ICU) following a Fontan surgical procedu…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49794/psn-pdf
    May 01, 2017 - Communication Error in a Closed ICU May 1, 2017 Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/communication-error-closed-icu The Case A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney transplant), co…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49583/psn-pdf
    April 01, 2009 - Eptifibatide Epilogue April 1, 2009 Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/eptifibatide-epilogue The Case A 62-year-old man was admitted at 11:00 PM on a Saturday night with the provisional diagnosis of acute coronary syndrome. Serial testing for mark…
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