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Total Results: 466 records

Showing results for "happen".

301. Are We Safer Today? | PSNet
     psnet.ahrq.gov/perspective/are-we-safer-today
     February 26, 2025 - But that does not happen now at most institutions or even for the best checklists.

302. Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle | PSNet
     psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
     July 23, 2024 - They should never happen in the provision of health care. 4   Per the Centers for Medicare and Medicaid

303. Readmissions and Adverse Events After Discharge | PSNet
     psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
     April 27, 2022 - Readmissions and Adverse Events After Discharge Citation Text: Readmissions and Adverse Events After Discharge. 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…

304. The Unfinished Patient Safety Agenda | PSNet
     psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda
     August 01, 2005 - RW: What can make these changes happen?

305. Medication Reconciliation Pitfalls | PSNet
     psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
     May 01, 2006 - and assured them that the case would be carefully reviewed to ensure that a similar error wouldn't happen

306. The Unintended Consequences of Florida Medical Liability Legislation | PSNet
     psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation
     February 01, 2003 - there is no learning from mistakes and near misses, increasing the chances that adverse events will happen

307. Handoffs | PSNet
     psnet.ahrq.gov/primer/handoffs
     October 18, 2023 - Handoffs Citation Text: Handoffs and Signouts. 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 7 XML Endnote tagged PubMedId RIS Download…

308. Dangerous Shift | PSNet
     psnet.ahrq.gov/web-mm/dangerous-shift
     July 24, 2013 - SPOTLIGHT CASE Dangerous Shift Citation Text: Patterson ES. Dangerous Shift. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…

309. Unexplained Apnea Under Anesthesia | PSNet
     psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
     December 01, 2005 - SPOTLIGHT CASE Unexplained Apnea Under Anesthesia Citation Text: Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX …

310. The Case of Mistaken Intubation | PSNet
     psnet.ahrq.gov/web-mm/case-mistaken-intubation
     July 01, 2016 - SPOTLIGHT CASE The Case of Mistaken Intubation Citation Text: Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX End…

311. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected | PSNet
     psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
     September 25, 2024 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected Citation Text: Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…

312. In Conversation With… Christopher P. Landrigan, MD, MPH | PSNet
     psnet.ahrq.gov/perspective/conversation-christopher-p-landrigan-md-mph
     April 01, 2013 - In specialties with a robust enough workforce that can afford for that to happen, it's a hugely beneficial

313. CE/MOC Quizzes | PSNet
     psnet.ahrq.gov/cme
     February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations A man with a history of prior umbilical hernia repair presented to the emergency department (ED) with abdominal pain and was initially diagnosed with cholelithiasis before being discharged home. However, the next day he returned to …

314. Hypoxemia after Emergency Intubation | PSNet
     psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
     March 24, 2019 - Hypoxemia after Emergency Intubation Citation Text: Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…

315. Are Residency Duty Hour Rules Improving Patient Safety? | PSNet
     psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
     April 01, 2013 - In specialties with a robust enough workforce that can afford for that to happen, it's a hugely beneficial

316. Patient Safety and Health Information Technology: Learning from Our Mistakes | PSNet
     psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
     July 01, 2012 - Patient Safety and Health Information Technology: Learning from Our Mistakes Ross Koppel, PhD | July 1, 2012  Also Read a Conversation View more articles from the same authors. Citation Text: Koppel R. Patient Safety and Health Information Technology: Learning f…

317. The Weekend Effect in Cardiology: Is It Real? If So, Can It Be Fixed? | PSNet
     psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed
     June 01, 2017 - I happen to think it is a real effect and it's not accounted for by case mix or other biases or confounders

318. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk | PSNet
     psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
     January 31, 2024 - Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk Citation Text: Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quali…

319. Learning Health Systems for Patient Safety | PSNet
     psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
     February 26, 2025 - Shared learning and improvements in patient safety happen when learning health systems with a strong

320. In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety | PSNet
     psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
     February 26, 2025 - Shared learning and improvements in patient safety happen when learning health systems with a strong