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Total Results: 1,790 records

Showing results for "happened".

  1. Innovations in Promoting Hand Hygiene Compliance | PSNet

    psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
    May 01, 2014 - author actually introduced the alcohol-based hand rub to the bedside and did nothing else, nothing happened

  2. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture | PSNet

    psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
    March 15, 2023 - SPOTLIGHT CASE Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture Citation Text: Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.. PSNet [internet]. Rockville (MD): Agency fo…

  3. 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…

  4. 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…

  5. In Conversation With… Shantanu Nundy, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-shantanu-nundy-md
    February 26, 2025 - In Conversation With… Shantanu Nundy, MD July 1, 2018  Citation Text: In Conversation With… Shantanu Nundy, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format:…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846975/psn-pdf
    March 28, 2023 - In Conversation with... Christie Allen about Maternal Safety and Perinatal Mental Health March 28, 2023 In Conversation with.. Christie Allen about Maternal Safety and Perinatal Mental Health. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-christie-allen-about-maternal-safety-and-perinatal…

  7. 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…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60542/psn-pdf
    May 27, 2020 - Life-Threatening Infant Overdose of Sodium Chloride May 27, 2020 Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride The Case  An infant with trisomy 21 underwent repair of a…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857061/psn-pdf
    November 27, 2023 - In Conversation with... Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety November 27, 2023 Stanley J. In Conversation with.. Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-joa…

  10. Becoming a Certified Professional in Patient Safety—A Registered Nurse's Perspective | PSNet

    psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-registered-nurses-perspective
    June 01, 2016 - Becoming a Certified Professional in Patient Safety—A Registered Nurse's Perspective Karen Frank, DNP, RN, MSHA | June 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Frank K. Becoming a Certified Professional in Patien…

  11. Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx Spotlight Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes Source and Credits • This presentation is based on the April 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/we…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849661/psn-pdf
    June 28, 2023 - Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery June 28, 2023 Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery. PSNet [internet]. 2023. https://psnet.ahrq.gov/web…

  13. 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…

  14. 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…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853081/psn-pdf
    August 30, 2023 - In Conversation with... Kathleen Sanford and Sue Schuelke about Virtual Nursing August 30, 2023 Sanford K, Schuelke S, Lee M, et al. In Conversation with.. Kathleen Sanford and Sue Schuelke about Virtual Nursing. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schue…

  16. In Conversation With... Freya Spielberg, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
    September 28, 2022 - In Conversation With... Freya Spielberg, MD, MPH September 28, 2022  Also Read the Essay Citation Text: In Conversation With.. Freya Spielberg, MD, MPH. PSNet [internet]. 2022.In Conversation With... Freya Spielberg, MD, MPH. PSNet [internet]. Rockville (MD): Agen…

  17. Life-Threatening Infant Overdose of Sodium Chloride | PSNet

    psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
    December 23, 2020 - Life-Threatening Infant Overdose of Sodium Chloride Citation Text: Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Form…

  18. In Conversation With… Lawrence Smith, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
    February 01, 2012 - In Conversation With… Lawrence Smith, MD February 1, 2012  Also Read an Essay Citation Text: In Conversation With… Lawrence Smith, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. …

  19. In Conversation with…Peter J. Pronovost, MD, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
    June 01, 2005 - In Conversation with…Peter J. Pronovost, MD, PhD June 1, 2005  Also Read an Essay Citation Text: In Conversation with…Peter J. Pronovost, MD, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servi…

  20. Missed Opportunities for Suicide Risk Assessment | PSNet

    psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
    September 27, 2023 - SPOTLIGHT CASE Missed Opportunities for Suicide Risk Assessment Citation Text: Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation For…
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