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Total Results: 1,790 records

Showing results for "happened".

  1. 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.

  2. Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
    January 01, 2023 - • It is not entirely clear what happened, but aggressive diuresis with concurrent diarrhea, possibly

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50754/psn-pdf
    December 18, 2019 - possible that fatigue and burnout contributed to the resident’s failure to enter the orders promptly as happened

  4. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
    January 01, 2024 - Precipitating factors include direct irritation of atrial tissue by the venous cannula (as appears to have happened

  5. WebM&M: Case Studies | PSNet

    psnet.ahrq.gov/webmm-case-studies
    March 25, 2025 - and embarrassed that the patient remembered waking up during the operation but could not explain what happened

  6. Total Parenteral Nutrition, Multifarious Errors | PSNet

    psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
    January 23, 2017 - misconnections, and ineffective or nonexistent systems of independent double-checks.( 14 ) However, as happened

  7. 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…

  8. 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…

  9. 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

  10. 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

  11. In Conversation With... Dr. Michelle Schreiber on Measuring Patient Safety | PSNet

    psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
    December 14, 2022 - In Conversation With... Dr. Michelle Schreiber on Measuring Patient Safety December 14, 2022  Also Read the Essay Citation Text: In Conversation With.. Dr. Michelle Schreiber on Measuring Patient Safety. PSNet [internet]. 2022.In Conversation With... Dr. Michelle …

  12. Measuring Patient Safety | PSNet

    psnet.ahrq.gov/perspective/measuring-patient-safety
    December 14, 2022 - Measuring Patient Safety Michelle Schreiber, MD; Cindy Van, MHSA; Sarah E. Mossburg, RN, PhD | December 14, 2022  Also Read the Conversation View more articles from the same authors. Citation Text: Schreiber M, Van C, Mossburg SE. Measuring Patient Safety. PSN…

  13. 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

  14. 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…

  15. 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…

  16. In Conversation With… Vineet Chopra, MD, MSc | PSNet

    psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
    February 28, 2024 - In Conversation With… Vineet Chopra, MD, MSc October 30, 2019  Citation Text: In Conversation With… Vineet Chopra, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation…

  17. In Conversation with…Donald M. Berwick, MD, MPP | PSNet

    psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
    November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP November 1, 2005  Also Read an Essay Citation Text: In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867656/psn-pdf
    February 26, 2025 - In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety February 26, 2025 Savitz LA, Sousane Z, Mossburg SE. In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learnin…

  19. The Safety of Medical Devices | PSNet

    psnet.ahrq.gov/perspective/safety-medical-devices
    June 01, 2011 - The Safety of Medical Devices Christopher Nemeth, PhD | June 1, 2011  Also Read a Conversation View more articles from the same authors. Citation Text: Nemeth CP. The Safety of Medical Devices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and…

  20. Playing Well with Others: "Translocational Research" in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
    September 01, 2005 - Playing Well with Others: "Translocational Research" in Patient Safety Robert M. Wachter, MD | September 1, 2005  Also Read a Conversation View more articles from the same authors. Citation Text: Wachter R. Playing Well with Others: "Translocational Research" in…
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