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Showing results for "happened".

  1. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-317
    November 30, 2021 - November 10, 2021 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, repor…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846564/psn-pdf
    March 29, 2023 - Technology as a Tool for Improving Patient Safety March 29, 2023 Holmgren AJ, McBride S, Gale B, et al. Technology as a Tool for Improving Patient Safety . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety Introduction  In the past several decades, technological a…

  3. 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 - SPOTLIGHT CASE The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy Citation Text: Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcar…

  4. Duplicate Therapies in Retail Pharmacy | PSNet

    psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
    August 05, 2022 - Duplicate Therapies in Retail Pharmacy Citation Text: Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX E…

  5. Nothing Called Small Surgery | PSNet

    psnet.ahrq.gov/web-mm/nothing-called-small-surgery
    February 01, 2023 - Nothing Called Small Surgery Citation Text: Manske C. Nothing Called Small Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

  6. 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: …

  7. 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 - Delayed Breast Cancer Diagnosis: A False Sense of Security. Citation Text: Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Cita…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866826/psn-pdf
    September 25, 2024 - Hypoxic Gas Supply from Cross-Connected Pipelines September 25, 2024 Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines The Case An 8-year-old boy with no significant past medical…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72589/psn-pdf
    December 23, 2020 - Delayed Breast Cancer Diagnosis: A False Sense of Security. December 23, 2020 Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security The Case A 60-year-old woman was se…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50698/psn-pdf
    November 27, 2019 - Missed Opportunities for Suicide Risk Assessment November 27, 2019 Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849679/psn-pdf
    June 28, 2023 - Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture June 28, 2023 Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/under-pressure-tracheost…

  12. 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…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49753/psn-pdf
    February 01, 2016 - Robotic Surgery: Risks vs. Rewards February 1, 2016 Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards Case Objectives Discuss the background and current trends in robotic surgery. Identify the benefits of robotic s…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33862/psn-pdf
    July 01, 2018 - In Conversation With… Shantanu Nundy, MD July 1, 2018 In Conversation With… Shantanu Nundy, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-shantanu-nundy-md Editor's note: Dr. Nundy is the Director of the nonprofit organization called the Human Diagnosis Project, a unique effort to cro…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865413/psn-pdf
    March 27, 2024 - In Conversation with...Barbara Pelletreau and John Riggi about Cybersecurity March 27, 2024 Pelletreau B, Riggi J. In Conversation with..Barbara Pelletreau and John Riggi about Cybersecurity. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cyberse…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863649/psn-pdf
    February 28, 2024 - In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0 February 28, 2024 In Conversation With..Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withstephen-…

  17. 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…

  18. Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx Spotlight Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See…

  19. 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 …

  20. In Conversation With… Didier Pittet, MD, MS | PSNet

    psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
    May 01, 2014 - author actually introduced the alcohol-based hand rub to the bedside and did nothing else, nothing happened
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