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Total Results: 2,541 records

Showing results for "incident".

2321. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations | PSNet
      psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
      September 27, 2023 - SPOTLIGHT CASE Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations Citation Text: Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…

2322. Long-term Care and Patient Safety | PSNet
      psnet.ahrq.gov/primer/long-term-care-and-patient-safety
      February 24, 2022 - Long-term Care and Patient Safety Citation Text: Bakerjian D. Long-term Care and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

2323. Who Nose Where the Airway Is? | PSNet
      psnet.ahrq.gov/web-mm/who-nose-where-airway
      May 01, 2016 - Who Nose Where the Airway Is? Citation Text: Lee CR. Who Nose Where the Airway Is?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

2324. The Hidden Danger of Unseen Intravenous Catheters | PSNet
      psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
      October 04, 2023 - The Hidden Danger of Unseen Intravenous Catheters Citation Text: Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google S…

2325. How Do Providers Recover From Errors? | PSNet
      psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
      May 22, 2024 - SPOTLIGHT CASE How Do Providers Recover From Errors? Citation Text: West CP. How Do Providers Recover From Errors?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar Bi…

2326. Discharge Fumbles | PSNet
      psnet.ahrq.gov/web-mm/discharge-fumbles
      September 09, 2009 - SPOTLIGHT CASE Discharge Fumbles Citation Text: Forster AJ. Discharge Fumbles. 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 End…

2327. What Happened on Telemetry? | PSNet
      psnet.ahrq.gov/web-mm/what-happened-telemetry
      January 18, 2012 - The institution wanted to explore this incident and the other common safety issues with telemetry monitoring

2328. The Deadly Duo | PSNet
      psnet.ahrq.gov/web-mm/deadly-duo
      April 28, 2021 - May 5, 2014 The effects of hospital-physician financial integration on adverse incident

2329. Hypoxic Gas Supply from Cross-Connected Pipelines | PSNet
      psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
      February 05, 2020 - February 5, 2020 Barriers and facilitators to incident reporting in mental healthcare

2330. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. | PSNet
      psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
      November 30, 2021 - SBAR improves communication and safety climate and decreases incident reports due to communication errors

2331. Getting to the Root of the Matter | PSNet
      psnet.ahrq.gov/web-mm/getting-root-matter
      September 01, 2005 - with key staff involved in the error (to establish a chronological flow of events), careful review of incident

2332. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
      January 01, 2024 - Spotlight Spotlight Do Not Miss Sepsis Needles in Viral Haystacks! Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Michelle Hamline, MD, PhD, MAS and Ulfat Shaikh, MD, M…

2333. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33608/psn-pdf
      February 01, 2024 - Maternal Safety January 31, 2024 Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. 2024. https://psnet.ahrq.gov/primer/maternal-safety Originally published in 2018 by researchers at the University of California, San Francisco. Updated in February 2024 by Marla Shauer, PhD(c), MSN, CNM, Amy Nichols,…

2334. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33567/psn-pdf
      June 15, 2024 - Handoffs June 15, 2024 Handoffs and Signouts. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/handoffs PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in 2024. Backgroun…

2335. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49729/psn-pdf
      April 01, 2015 - Dissecting the Presentation April 1, 2015 Suat-Ooi SB. Dissecting the Presentation. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/dissecting-presentation Case Objectives Define aortic dissection. Describe the epidemiology of acute aortic dissection. State the common and uncommon presentation of acute aor…

2336. Patient Safety in the Ambulatory Care Setting | PSNet
      psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
      April 27, 2022 - Annual Perspective Patient Safety in the Ambulatory Care Setting August 5, 2022  View more articles from the same authors. Citation Text: Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet]. Rockville (MD): …

2337. Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors | PSNet
      psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
      May 31, 2023 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL March 3, 2021 Innovation…

2338. Impatient Inpatient Dosing | PSNet
      psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
      June 24, 2020 - SPOTLIGHT CASE Impatient Inpatient Dosing Citation Text: White RH. Impatient Inpatient Dosing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…

2339. Abdominal Pain in Early Pregnancy | PSNet
      psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy
      November 13, 2024 - SPOTLIGHT CASE Abdominal Pain in Early Pregnancy Citation Text: Kilpatrick CC. Abdominal Pain in Early Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibT…

2340. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. | PSNet
      psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
      June 28, 2023 - SPOTLIGHT CASE Prolonged DKA in Pregnancy: A Case of Communication Breakdown. Citation Text: Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services…