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Showing results for "happen".

  1. 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…

  2. Good Catch in the Operating Room | PSNet

    psnet.ahrq.gov/web-mm/good-catch-operating-room
    August 27, 2017 - Good Catch in the Operating Room Citation Text: Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …

  3. The "Customer" Is Always Right | PSNet

    psnet.ahrq.gov/web-mm/customer-always-right
    January 22, 2014 - SPOTLIGHT CASE The "Customer" Is Always Right Citation Text: Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote…

  4. Check the Wristband | PSNet

    psnet.ahrq.gov/web-mm/check-wristband
    August 03, 2009 - Check the Wristband Citation Text: Rosenthal M. Check the Wristband. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

  5. 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…

  6. Standard Deviations | PSNet

    psnet.ahrq.gov/web-mm/standard-deviations
    January 01, 2006 - SPOTLIGHT CASE Standard Deviations Citation Text: Sabin JE. Standard Deviations. 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 E…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854897/psn-pdf
    October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose October 31, 2023 Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/weight-and-…

  8. Engaging Seriously Ill Older Patients in Advance Care Planning | PSNet

    psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
    December 22, 2018 - SPOTLIGHT CASE Engaging Seriously Ill Older Patients in Advance Care Planning Citation Text: Heyland DK. Engaging Seriously Ill Older Patients in Advance Care Planning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49570/psn-pdf
    October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure? October 1, 2008 Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure Case Objectives Understand the complementary abilities of an electronic health record a…

  10. Who Nose Where the Airway Is? | PSNet

    psnet.ahrq.gov/web-mm/who-nose-where-airway
    May 01, 2016 - Who Nose Where the Airway Is? Citation Text: Lee CR. Who Nose Where the Airway Is?. 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 t…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49864/psn-pdf
    June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout June 1, 2019 Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…

  12. 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…

  13. The Hidden Danger of Unseen Intravenous Catheters | PSNet

    psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
    October 04, 2023 - The Hidden Danger of Unseen Intravenous Catheters Citation Text: Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google S…

  14. 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…

  15. 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 …

  16. 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 …

  17. 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. …

  18. 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…

  19. 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…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49639/psn-pdf
    November 01, 2011 - Near Miss with Bedside Medications November 1, 2011 Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications Case Objectives Understanding the definition of near miss—also known as close call. Appreciate the importance of close calls in reducin…
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