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Total Results: 466 records

Showing results for "happen".

421. Delirium or Dementia? | PSNet
     psnet.ahrq.gov/web-mm/delirium-or-dementia
     September 27, 2023 - SPOTLIGHT CASE Delirium or Dementia? Citation Text: Rudolph JL. Delirium or Dementia?. 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…

422. Technology as a Tool for Improving Patient Safety | PSNet
     psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
     April 26, 2023 - Annual Perspective Technology as a Tool for Improving Patient Safety A Jay Holmgren, Susan McBride,Bryan Gale, Sarah Mossburg | March 29, 2023  View more articles from the same authors. Citation Text: Holmgren AJ, McBride S, Gale B, et al. Technology as a …

423. An Incomplete Anesthesia History Leads to Adverse Outcomes | PSNet
     psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
     January 29, 2021 - An Incomplete Anesthesia History Leads to Adverse Outcomes Citation Text: Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: …

424. Ensuring Patient and Workforce Safety Culture in Healthcare | PSNet
     psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
     March 27, 2024 - Annual Perspective Ensuring Patient and Workforce Safety Culture in Healthcare John Murray, Joann Sorra, Bryan Gale, Sarah Mossburg | March 27, 2024  View more articles from the same authors. Citation Text: Murray J, Sorra J, Gale B, et al. Ensuring Patient…

425. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867497/psn-pdf
     February 26, 2025 - Retained Surgical Items: Causation and Prevention February 26, 2025 Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention Background A retained surgical item (RSI) is a surgical patient safety pro…

426. Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. | PSNet
     psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
     August 14, 2024 - SPOTLIGHT CASE Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. Citation Text: Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…

427. Balancing Supervision and Autonomy: An Ongoing Tension | PSNet
     psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension
     February 01, 2012 - Mistakes may happen because you allow people a little bit of room in their training to be autonomous.

428. Unintended Consequences of CPOE | PSNet
     psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
     September 01, 2004 - SPOTLIGHT CASE Unintended Consequences of CPOE Citation Text: Wears RL. Unintended Consequences of CPOE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNot…

429. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality | PSNet
     psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
     October 01, 2004 - SPOTLIGHT CASE Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality Citation Text: Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. Rockville (MD): Agency for Healthcare Res…

430. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49801/psn-pdf
     August 01, 2017 - Despite Clues, Failed to Rescue August 1, 2017 Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue Case Objectives Define failure to rescue. Identify the main contributors to failure-to-rescue events. Appreciate the ongoing areas of scien…

431. Which Line: Ordering Provider or Proceduralist? | PSNet
     psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
     September 16, 2015 - SPOTLIGHT CASE Which Line: Ordering Provider or Proceduralist? Citation Text: Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …

432. Robotic Surgery: Risks vs. Rewards | PSNet
     psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
     October 31, 2023 - SPOTLIGHT CASE Robotic Surgery: Risks vs. Rewards Citation Text: Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Googl…

433. Hypoxic Gas Supply from Cross-Connected Pipelines | PSNet
     psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
     February 05, 2020 - Hypoxic Gas Supply from Cross-Connected Pipelines Citation Text: Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google S…

434. Retained Surgical Items: Causation and Prevention | PSNet
     psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
     January 04, 2024 - Retained Surgical Items: Causation and Prevention Citation Text: Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX End…

435. WebM&M: Case Studies | PSNet
     psnet.ahrq.gov/webmm-case-studies
     March 25, 2025 - WebM&M: Case Studies WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME/CPE . Commentaries are written by patient safety experts and published monthly. Have you encou…

436. Despite Clues, Failed to Rescue | PSNet
     psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
     August 02, 2015 - SPOTLIGHT CASE Despite Clues, Failed to Rescue Citation Text: Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndN…

437. In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0 | PSNet
     psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
     February 28, 2024 - It is easy to talk about how communication should happen, for example, in a surgery unit in a hospital

438. Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training | PSNet
     psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
     February 28, 2024 - It is easy to talk about how communication should happen, for example, in a surgery unit in a hospital

439. In Conversation With… Gregg S. Meyer, MD, MSc | PSNet
     psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc
     June 01, 2016 - When I think back to my days at AHRQ, we had a fantasy that something like this would begin to happen

440. The Role of Bar Coding and Smart Pumps in Safety | PSNet
     psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
     September 01, 2008 - RW: Given that such a high percentage of errors in the medication process happen at a point that begins