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Showing results for "happened".

1461. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49587/psn-pdf
      May 01, 2009 - Missing Trauma May 1, 2009 Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/missing-trauma The Case A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a few minutes later by a customer, who immediately called 911. On arrival, para…

1462. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33846/psn-pdf
      November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety November 1, 2017 Rozenblum R, Bates DW. The Role of Patient-facing Technologies to Empower Patients and Improve Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-imp…

1463. Spotlight Case (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.127_slideshow.ppt
      May 01, 2006 - Spotlight Case Spotlight Case May 2006 Right? Left? Neither! Source and Credits This presentation is based on the May 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD…

1464. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience | PSNet
      psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
      December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005  View more articles from the same authors. Citation Text: Conway JB, Weingart SN. Organizational Change…

1465. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849660/psn-pdf
      May 31, 2023 - Strategies to Improve Organizational Health Literacy. May 31, 2023 Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy Background Health literacy is important at both the personal …

1466. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49438/psn-pdf
      March 05, 2004 - OR Peeping March 1, 2004 Mackenzie CF. OR Peeping. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/or-peeping The Case A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete spontaneous abortion (miscarriage). At this community hospital, a new operating room (OR) su…

1467. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33676/psn-pdf
      November 01, 2008 - In Conversation with…Sanjay Saint, MD, MPH November 1, 2008 In Conversation with…Sanjay Saint, MD, MPH. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph Editor's note: Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann Arbor VA …

1468. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33621/psn-pdf
      November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience November 1, 2005 Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience Perspective Health care organizations throughout the world have ide…

1469. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49595/psn-pdf
      December 01, 2009 - "Superficial" Report Leads to "Deep" Problem December 1, 2009 Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem The Case A 35-year-old woman presented to the emergency department (ED) complaining of left foot and an…

1470. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34773/psn-pdf
      March 08, 2017 - Medication Errors: The Nursing Experience. March 8, 2017 Wolf ZR. Albany NY: Delmar Publishers; 1994. ISBN: 9780827362628. https://psnet.ahrq.gov/issue/medication-errors-nursing-experience In one of the first professional books to deal with medication error from the nursing perspective, Wolf provides a comprehensi…

1471. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34854/psn-pdf
      March 28, 2005 - Preventing lawsuits: Coalition pushes apologies and cash up-front. Dealing with medical errors when they happen-- instead of in court--can benefit doctors and patients, supporters say. March 28, 2005 Albert T. AMNews. February 7, 2005. https://psnet.ahrq.gov/issue/preventing-lawsuits-coalition-pushes-apologies-an…

1472. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36499/psn-pdf
      January 07, 2011 - Retrospective analysis of medication incidents reported using an on-line reporting system. January 7, 2011 Ashcroft DM, Cooke J. Retrospective analysis of medication incidents reported using an on-line reporting system. Pharmacy World & Science. 2006;28(6). doi:10.1007/s11096-006-9040-8. https://psnet.ahrq.gov/iss…

1473. In Conversation With… Matthew Weinger, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-matthew-weinger-md
      August 01, 2018 - Why hasn't that happened? MW : It's a function of the structure of health care.

1474. Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients. | PSNet
      psnet.ahrq.gov/issue/use-interactive-telephone-based-self-management-support-program-identify-adverse-events-among
      June 11, 2010 - Study Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients. Citation Text: Sarkar U, Handley MA, Gupta R, et al. Use of an interactive, telephone-based self-management support program to identify adverse ev…

1475. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33613/psn-pdf
      May 01, 2005 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience May 1, 2005 Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience Pe…

1476. In Conversation with…Christopher P. Landrigan, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
      April 01, 2005 - However, it turned out that this kind of thing happened only a handful of times over the life of the

1477. Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet) | PSNet
      psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet
      April 01, 2005 - However, it turned out that this kind of thing happened only a handful of times over the life of the

1478. In Conversation With… Andrew Gettinger, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
      September 01, 2017 - of federal funding really changed the inflection point and pushed adoption faster than it would have happened … Thus, unforeseen events happened more frequently and were more severe than anyone predicted.( 12 ) Over

1479. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45936/psn-pdf
      March 08, 2017 - Using information from external errors to signal a "clear and present danger." March 8, 2017 ISMP Medication Safety Alert! Acute care edition. February 9, 2017;22:1-5. https://psnet.ahrq.gov/issue/using-information-external-errors-signal-clear-and-present-danger Monitoring external reports of error and harm can pr…

1480. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42346/psn-pdf
      June 10, 2018 - Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. May 30, 2013;18:1-3. https://psnet.ahrq.gov/issue/fatal-pca-adverse-events-continue-happenbetter-patient-monitoring-essential- prevent-harm Describi…