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Showing results for "happen".

  1. Signout Fallout | PSNet

    psnet.ahrq.gov/web-mm/signout-fallout
    November 16, 2022 - SPOTLIGHT CASE Signout Fallout Citation Text: Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…

  2. Tough Call: Addressing Errors From Previous Providers | PSNet

    psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
    July 17, 2024 - SPOTLIGHT CASE Tough Call: Addressing Errors From Previous Providers Citation Text: Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy…

  3. e3iVR: Conference on Ethics in Investigational and Interventional Uses of Immersive VR - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/r13hs024833-gill-final-report-2017.pdf
    January 01, 2017 - e3iVR: Conference on Ethics in Investigational and Interventional Uses of Immersive VR - Final Report e3iVR: Conference on ethics in investigational and interventional uses of …

  4. No News May Not Be Good News | PSNet

    psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
    December 07, 2009 - SPOTLIGHT CASE No News May Not Be Good News Citation Text: Moore CR. No News May Not Be Good News. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…

  5. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? | PSNet

    psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
    March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? Citation Text: Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. C…

  6. Transitions in Adolescent Medicine | PSNet

    psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
    August 04, 2021 - Transitions in Adolescent Medicine Citation Text: Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 …

  7. Out of Sight, Out of Mind: Out-of-Office Test Result Management | PSNet

    psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
    September 01, 2007 - SPOTLIGHT CASE Out of Sight, Out of Mind: Out-of-Office Test Result Management Citation Text: Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …

  8. Order Interrupted by Text: Multitasking Mishap | PSNet

    psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
    August 21, 2015 - SPOTLIGHT CASE Order Interrupted by Text: Multitasking Mishap Citation Text: Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: …

  9. Fagerlin-notes-151007 copy-Teresa (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/fagerlin-presentation.pdf
    May 29, 2025 - Fagerlin-notes-151007 copy-Teresa When  we talk about patient engagement and  shared  decision-­‐making there are a number of different problems that evolve. 1 First, patients often do not have information they need to make decisions, nor are they involved in the  decisions as much  as they would  …

  10. Transfer Troubles | PSNet

    psnet.ahrq.gov/web-mm/transfer-troubles
    December 29, 2014 - SPOTLIGHT CASE Transfer Troubles Citation Text: Hains IM. Transfer Troubles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49522/psn-pdf
    November 01, 2006 - Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality November 1, 2006 Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-…

  12. In Conversation With... John G. Reiling, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd
    June 01, 2014 - In Conversation With... John G. Reiling, PhD December 1, 2012  Citation Text: In Conversation With.. John G. Reiling, PhD. PSNet [internet]. 2012.In Conversation With... John G. Reiling, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49675/psn-pdf
    February 01, 2013 - Delay in Treatment: Failure to Contact Patient Leads to Significant Complications February 1, 2013 Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complicat…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49585/psn-pdf
    May 01, 2009 - Delirium or Dementia? May 1, 2009 Rudolph JL. Delirium or Dementia? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/delirium-or-dementia Case Objectives State the key diagnostic differences between delirium and dementia. Describe the Confusion Assessment Method for workup of suspected delirium. Explain the…

  15. Executive Summary | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/summary.html
    August 01, 2022 - Demonstration Grants Final Evaluation Report Executive Summary Previous Page Next Page Table of Contents Demonstration Grants Final Evaluation Report Executive Summary Detailed Findings Evaluation Issues Contributions to Patient Safety and Medical Liability Lessons Learned From Implement…

  16. How are CHIPRA quality demonstration States working together to improve the quality of health care for children? | Agency for Healthcare Research and Quality

    www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight06.html
    January 01, 2014 - How are CHIPRA quality demonstration States working together to improve the quality of health care for children? Evaluation Highlight No. 6 Authors: Dana Petersen, Henry Ireys, Grace Ferry, and Leslie Foster Contents Key Messages Background Findings Conclusion Implications Learn More Endno…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837660/psn-pdf
    July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse Outcomes July 8, 2022 Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes The Cases Case 1: A 64-year-old man came in for a routine bron…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49771/psn-pdf
    July 01, 2016 - Unintended Consequences of CPOE October 1, 2016 Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe Case Objectives Explain how technology, including computerized provider order entry, can transform, rather than eliminate, hazards. Recogni…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49855/psn-pdf
    March 01, 2019 - Which Line: Ordering Provider or Proceduralist? March 1, 2019 Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist Case Objectives Review the role of mistake-proofing to block errors from leading to adverse…

  20. SOPS Diagnostic Safety Pilot Study Report (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/diagnostic-safety-pilot-study-report.pdf
    April 01, 2021 - SOPS Diagnostic Safety Pilot Study Report Pilot Study Results From the AHRQ Surveys on Patient Safety CultureTM (SOPS®) Diagnostic Safety Supplemental Items for Medical Offices Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 5600 Fishers Lane Rockvil…
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