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Showing results for "identifying".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38176/psn-pdf
    October 29, 2008 - Human error, not communication and systems, underlies surgical complications. October 29, 2008 Fabri PJ, Zayas-Castro JL. Human error, not communication and systems, underlies surgical complications. Surgery. 2008;144(4):557-63; discussion 563-5. doi:10.1016/j.surg.2008.06.011. https://psnet.ahrq.gov/issue/human-e…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33928/psn-pdf
    June 23, 2015 - Anesthesia safety: model or myth? A review of the published literature and analysis of current original data. June 23, 2015 Lagasse RS. Anesthesia safety: model or myth? A review of the published literature and analysis of current original data. Anesthesiology. 2002;97(6):1609-17. https://psnet.ahrq.gov/issue/anes…

  3. Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. | PSNet

    psnet.ahrq.gov/issue/hospital-board-and-management-practices-are-strongly-related-hospital-performance-clinical
    October 27, 2021 - Study Classic Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. Citation Text: Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to hospital performanc…

  4. Using harm-based weights for the AHRQ Patient Safety for Selected Indicators composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans Health Administration hospitals? | PSNet

    psnet.ahrq.gov/issue/using-harm-based-weights-ahrq-patient-safety-selected-indicators-composite-psi-90-does-it
    March 15, 2016 - Study Using harm-based weights for the AHRQ Patient Safety for Selected Indicators composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans Health Administration hospitals? Citation Text: Chen Q, Rosen AK, Borzecki A, et al. Using Harm-Bas…

  5. In Conversation With… Hardeep Singh, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
    January 01, 2014 - institutional level, studies published this year demonstrated the effectiveness of a systematic approach to identifying … required to demonstrate that they can recognize system error and advocate for system improvement through identifying

  6. Coming Up Short | PSNet

    psnet.ahrq.gov/web-mm/coming-short
    May 20, 2020 - Coming Up Short Citation Text: Hochberg Z'ev. Coming Up Short. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

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

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
    November 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case November 2005 Reconciling Doses Source and Credits This presentation is based on the November 2005 Spotlight Case in Emergency Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Frank Federico, RPh,…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836878/psn-pdf
    April 27, 2022 - The Media’s Role in Patient Safety April 27, 2022 Millenson ML, Dowell P, Mossburg SE. The Media’s Role in Patient Safety. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/medias-role-patient-safety Brief History of the Media Influencing Patient Safety Despite studies raising questions about avoidable ha…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49421/psn-pdf
    October 01, 2003 - Urine a Tough Position October 1, 2003 Gandhi TK. Urine a Tough Position. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/urine-tough-position The Case A 22-year-old unmarried woman came to her doctor’s office worried that she might be pregnant. Although she did not want to have a baby at that time, she sta…

  10. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
    May 01, 2013 - Spotlight Case July 2008 Spotlight Case Right Regimen, Wrong Cancer: Patient Catches Medical Error * * Source and Credits This presentation is based on the May 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Joseph O. Jacobson, MD, MSc…

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

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.251_slideshow.ppt
    October 01, 2011 - Spotlight Case [MONTH] 2003 Spotlight Case Mobility Lost in the ICU * * Source and Credits This presentation is based on the October 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jim Smith, PT, DPT, MA; Associate Professor of Physical …

  12. PSNet Curated Library (pdf file)

    psnet.ahrq.gov/print/pdf/node/74277
    January 01, 2021 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Medication/Drug Errors Curated Library Primers Medication Administration Errors Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS | March, 12 2021 Medication administration errors are a persistent patient saf…

  13. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.308_slideshow.ppt
    October 01, 2013 - PowerPoint Presentation Spotlight Case It's Sarah, not Stephen! 1 This presentation is based on the October 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Urmimala Sarkar, MD, MPH, University of California at San Francisco Editor, AHRQ WebM&…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49691/psn-pdf
    September 01, 2013 - DRESSed for Failure September 1, 2013 Abramson EL, Kaushal R. DRESSed for Failure. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/dressed-failure The Case A 60-year-old woman who uses a wheelchair presented to the emergency department (ED) with right hand cellulitis and an uncomplicated urinary tract infec…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49492/psn-pdf
    November 01, 2005 - Reconciling Doses November 1, 2005 Federico F. Reconciling Doses. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/reconciling-doses Case Objectives List the steps involved in medication reconciliation. Describe the role of each of the stakeholders in medication reconciliation. Discuss how medication reconc…

  16. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment | PSNet

    psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
    June 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment Citation Text: Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49397/psn-pdf
    May 01, 2003 - The Dropped Lung May 1, 2003 Heffner JR. The Dropped Lung. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dropped-lung The Case A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…

  18. Critical Opportunity Lost | PSNet

    psnet.ahrq.gov/web-mm/critical-opportunity-lost
    February 17, 2017 - Critical Opportunity Lost Citation Text: Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49538/psn-pdf
    June 01, 2007 - Abnormal Volunteer Results June 1, 2007 Fernandez C. Abnormal Volunteer Results. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/abnormal-volunteer-results The Case A healthy 52-year-old woman volunteered to participate in a radiology study in which she underwent magnetic resonance imaging (MRI) of her abdo…

  20. Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy | PSNet

    psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergy
    July 08, 2022 - Physical paper charts had highly visible stickers identifying the patient with latex allergy.
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