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Showing results for "happen".

1541. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49408/psn-pdf
      July 01, 2003 - Check the Wristband July 1, 2003 Rosenthal M. Check the Wristband. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/check-wristband The Case The patient was a 28-year-old female awaiting ambulatory surgery. She was very anxious about the impending surgery. The patient spoke English and appeared to be of aver…

1542. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49528/psn-pdf
      January 01, 2015 - The "Customer" Is Always Right February 1, 2007 Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/customer-always-right Case Objectives Understand the importance of identifying a patient's agenda. Appreciate the factors that contribute to unmet patient expectations. …

1543. Spotlight (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
      January 01, 2019 - Spotlight Spotlight Mistaken Attribution, Diagnostic Misstep * Source and Credits This presentation is based on the January 2019 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD …

1544. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49654/psn-pdf
      June 01, 2012 - Transfer Troubles June 1, 2012 Hains IM. Transfer Troubles. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfer-troubles Case Objectives Recognize that transfer of patients between hospitals is common. Understand the frequency of errors and adverse events in the transfer of patients between hospitals. …

1545. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49828/psn-pdf
      May 01, 2018 - Out of Sight, Out of Mind: Out-of-Office Test Result Management May 1, 2018 Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management Case Objectives Recognize the general responsibilities of…

1546. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49550/psn-pdf
      December 01, 2007 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? December 1, 2007 Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals The Case …

1547. Continuing Education | PSNet
      psnet.ahrq.gov/continuing-education
      February 26, 2025 - Continuing Education What is PSNet Continuing Education? PSNet Continuing Education offerings include WebM&M Spotlight Cases and Commentaries, which are certified for Continuing Medical Education/Continuing Education Units (CME/CEU) and Maintenance of Certification (MOC) credit through the University of Calif…

1548. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose | PSNet
      psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
      March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose Citation Text: Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…

1549. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852808/psn-pdf
      August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication Breakdown. August 30, 2023 Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown Disclosure of Relevant Financial Relationship…

1550. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
      January 01, 2023 - Spotlight Spotlight Prolonged DKA in Pregnancy: A Case of Communication Breakdown Source and Credits • This presentation is based on the August 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Sarah Marshall, MD and Nina M. …

1551. 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…

1552. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49660/psn-pdf
      August 01, 2012 - No News May Not Be Good News August 1, 2012 Moore CR. No News May Not Be Good News. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news Case Objectives Describe the frequency with which ambulatory test results are not followed up by providers. Appreciate that inadequate follow-up of…

1553. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49702/psn-pdf
      March 01, 2014 - Tough Call: Addressing Errors From Previous Providers March 1, 2014 Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers Case Objectives Define what it means to be a professional. Identi…

1554. Mechanical Prosthetic Valve Thrombosis with Thromboembolism. | PSNet
      psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
      August 21, 2005 - Mechanical Prosthetic Valve Thrombosis with Thromboembolism. Citation Text: Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation …

1555. Eptifibatide Epilogue | PSNet
      psnet.ahrq.gov/web-mm/eptifibatide-epilogue
      March 04, 2011 - Eptifibatide Epilogue Citation Text: Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …

1556. Communication Failure—Who's in Charge? | PSNet
      psnet.ahrq.gov/web-mm/communication-failure-whos-charge
      April 01, 2018 - Communication Failure—Who's in Charge? Citation Text: Fackler J, Schwartz JM. Communication Failure—Who's in Charge?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndN…

1557. The Consequences of Miscommunication Regarding a Possible Artifact | PSNet
      psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
      May 11, 2019 - SPOTLIGHT CASE The Consequences of Miscommunication Regarding a Possible Artifact Citation Text: Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…

1558. In Conversation With… Thomas J. Nasca, MD, MACP | PSNet
      psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
      July 10, 2024 - to come together because of the other pressures in the environment, or CLER is actually making that happen

1559. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49744/psn-pdf
      October 01, 2015 - Today, this doesn't happen.

1560. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50698/psn-pdf
      November 27, 2019 - suicide risk and medical decision- making capacity and while requests to leave against medical advice happen