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Total Results: 466 records

Showing results for "happen".

381. In Conversation with…Peter J. Pronovost, MD, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
     June 01, 2005 - characterized by a blend of methodologic sophistication and practical attention to the details of making change happen

382. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture | PSNet
     psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
     March 15, 2023 - Before this could happen, the patient developed increasing hypoxemia and respiratory distress, ultimately

383. Do Me a Favor | PSNet
     psnet.ahrq.gov/web-mm/do-me-favor
     September 12, 2016 - Do Me a Favor Citation Text: Williamson A. Do Me a Favor. 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 …

384. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. | PSNet
     psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
     February 21, 2020 - Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. Citation Text: Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. …

385. The Case for Patient Flow Management | PSNet
     psnet.ahrq.gov/web-mm/case-patient-flow-management
     February 23, 2019 - The Case for Patient Flow Management Citation Text: Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X…

386. "Recurrent" Appendicitis | PSNet
     psnet.ahrq.gov/web-mm/recurrent-appendicitis
     January 15, 2020 - "Recurrent" Appendicitis Citation Text: Greenberg CC. "Recurrent" Appendicitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…

387. 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…

388. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery | PSNet
     psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
     September 27, 2023 - standard preoperative huddle and pre-incision checklist likely contributed to this near miss, which may happen

389. 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…

390. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy | PSNet
     psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
     April 08, 2019 - Today, this doesn't happen.

391. Delayed Breast Cancer Diagnosis: A False Sense of Security. | PSNet
     psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
     May 01, 2005 - In addition, delayed diagnosis due to access barriers continues to happen frequently.

392. 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…

393. 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…

394. 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. …

395. Discharging Our Responsibility | PSNet
     psnet.ahrq.gov/web-mm/discharging-our-responsibility
     January 16, 2019 - Discharging Our Responsibility Citation Text: Fonarow GC. Discharging Our Responsibility. 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 X3 XML EndNote 7 XML End…

396. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up | PSNet
     psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom
     December 01, 2005 - An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up Robert M. Wachter, MD | June 1, 2012  View more articles from the same authors. Citation Text: Wachter R. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up. …

397. A Mistaken Dose of Naloxone  | PSNet
     psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
     March 21, 2009 - A Mistaken Dose of Naloxone  Citation Text: Cutler E, Gunawardena D. A Mistaken Dose of Naloxone . 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 …

398. After-Visit Confusion | PSNet
     psnet.ahrq.gov/web-mm/after-visit-confusion
     August 21, 2007 - After-Visit Confusion Citation Text: Ventres W. After-Visit Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…

399. In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet
     psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
     September 24, 2024 - You just spoke to the fact that harm does happen even in organizations that have a zero-harm goal.

400. A Tale of Two Falls | PSNet
     psnet.ahrq.gov/web-mm/tale-two-falls
     March 27, 2024 - Falls can happen at any age, but older adults are at higher risk given physiological changes.