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Showing results for "happened".

  1. 099-Cusp-Guide-Why-Choose-Cusp-Approach (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/099-cusp-guide-why-choose-cusp-approach.docx
    October 01, 2024 - AHRQ Safety Program for MRSA Prevention Why Choose a CUSP Approach? ICU & Non-ICU Slide Title and Commentary Slide Number and Slide Why Choose a CUSP Approach? SAY: Welcome to this presentation on the topic of “Why Choose a CUSP Approach?” The term CUSP is short for “the Comprehensive Unit-based Safety Program.” T…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49592/psn-pdf
    October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…

  3. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/physician-staff-engagement-facguide.docx
    January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle Slide Title and Commentary Slide Number and Slide Title Slide Physician and Staff Engagement SAY: Today, we will give you an overview of physician and staff engagement. Slide 1 Learning Objectives SAY: After this session, you will be able to identify the imp…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49493/psn-pdf
    November 01, 2005 - Infused, Not Ingested November 1, 2005 Foley M. Infused, Not Ingested. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/infused-not-ingested The Case A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering contrast, an unfamiliar task for this particular nurse. Rathe…

  5. Assess Patient Safety Culture Using the Hospital Survey on Patient Safety: Slide Presentation | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/mvp/modules/cusp/assess-psc-hsop-slides.html
    February 01, 2017 - Assess Patient Safety Culture Using the Hospital Survey on Patient Safety: Slide Presentation AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients Assess Patient Safety Culture Using the Hospital Survey on Patient Safety Slide 2: Lear…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72693/psn-pdf
    January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules January 29, 2021 Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules The Case A…

  7. OR Peeping | PSNet

    psnet.ahrq.gov/web-mm/or-peeping
    May 01, 2015 - OR Peeping Citation Text: Mackenzie CF. OR Peeping. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Dow…

  8. Acknowledging Our Track Chairs (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/2006ClancyKeyesYoung_051211comp.pdf
    June 16, 2021 - Acknowledging Our Track Chairs Acknowledging Our Track Chairs  Steve Simon, Harvard Medical School  Jack Starmer, Vanderbilt University  Atif Zafar, Indiana University  Marc Overhage, Regenstrief Institute  Mark Frisse, Vanderbilt University  Jan Walker, Partners Health Care and Cntr for Health IT Leadership  …

  9. Labor and Delivery Unit Safety: Umbilical Cord Prolapse | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-cord-prolapse.html
    July 01, 2023 - Labor and Delivery Unit Safety: Umbilical Cord Prolapse AHRQ Safety Program for Perinatal Care Purpose of the tool: This tool describes the key perinatal safety elements that support safe umbilical cord prolapse management. The key safety elements are presented within the framework of the Compreh…

  10. Quality Improvement in Action Slides

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/qi-action-slides.pptx
    April 01, 2022 - Quality Improvement in Action Slides Quality Improvement in Action AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI AHRQ Pub. No. 17(22)-0019 April 2022 Objectives Describe methods to identify your intensive care unit’s (ICU) focus area of improvement using quality improvement strategies R…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860049/psn-pdf
    January 04, 2024 - Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. January 4, 2024 Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient The Case A 9…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50842/psn-pdf
    January 29, 2020 - Patient Identification Errors: A Systems Challenge January 29, 2020 Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge The Cases The following four events involving five patients all involved…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49472/psn-pdf
    March 01, 2005 - Preventable Rash March 1, 2005 McLean C. Preventable Rash. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/preventable-rash The Case A 35-year-old man with HIV was being followed in an outpatient internal medicine clinic. At a routine visit, screening laboratories were checked. The clinic never contacted th…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851158/psn-pdf
    June 28, 2023 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization June 28, 2023 Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization The Case A patient was …

  15. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.140_slideshow.ppt
    December 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case December 2006 Hidden Heparins: HIT Happens Source and Credits This presentation is based on the December 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: Patrick F. Fogarty,…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49423/psn-pdf
    November 01, 2003 - The Missing Suction Tip November 1, 2003 Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missing-suction-tip Case Objectives Identify the risk factors for retained foreign bodies. Understand methods used to prevent and identify retained foreign bodies. Apprecia…

  17. From Emergency to Community: Implementing a Social Needs Assessment and Referral Infrastructure Using Health Information Technology | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/emergency-community-implementing-social-needs-assessment-and-referral
    January 01, 2024 - From Emergency to Community: Implementing a Social Needs Assessment and Referral Infrastructure Using Health Information Technology Project Final Report ( PDF , 700.28 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are r…

  18. Building a Safety Program Using Principles of Resilience Engineering | PSNet

    psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
    October 23, 2013 - Building a Safety Program Using Principles of Resilience Engineering Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS | June 1, 2019  View more articles from the same authors. Citation Text: Hegde S, Fairbanks RJ, Bisantz A. Building a Safety…

  19. Section 4: Ways To Approach the Quality Improvement Process (Page 2 of 2) | Agency for Healthcare Research and Quality

    www.ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qi-process/sect4part2.html
    January 01, 2020 - Section 4: Ways To Approach the Quality Improvement Process (Page 2 of 2) Contents Page 1 of 2 4.A. Focusing on Microsystems 4.B. Understanding and Implementing the Improvement Cycle Page 2 of 2 4.C. An Overview of Improvement Models 4.D. Tools To Enhance Quality Improvement Initiatives References…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49604/psn-pdf
    June 01, 2010 - Tacit Handover, Overt Mishap June 1, 2010 Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap The Case A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3 years earlier to treat an abdo…
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