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Total Results: 2,541 records

Showing results for "incident".

  1. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. | PSNet

    psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
    October 28, 2020 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. Citation Text: Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…

  2. Dangerous Shift | PSNet

    psnet.ahrq.gov/web-mm/dangerous-shift
    July 24, 2013 - SPOTLIGHT CASE Dangerous Shift Citation Text: Patterson ES. Dangerous Shift. 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 Endno…

  3. Project BOOST Increases Patient Understanding of Treatment and Follow-up Care | PSNet

    psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
    February 26, 2025 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 26, 2021 Innovation Contact …

  4. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia | PSNet

    psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
    January 29, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia Citation Text: Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and…

  5. ABCDEF Bundle Data Literacy Training, Performance Measurement Tracking, and Performance Feedback | PSNet

    psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
    September 23, 2024 - ABCDEF Bundle + Data Literacy Training, Performance Measurement Tracking, and Performance Feedback Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL February 28, 2024 Innovation Conta…

  6. Verbal Orders and Medication Overrides: A Dangerous Combination | PSNet

    psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
    September 27, 2023 - Verbal Orders and Medication Overrides: A Dangerous Combination Citation Text: Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…

  7. Cognitive Overload in the ICU | PSNet

    psnet.ahrq.gov/web-mm/cognitive-overload-icu
    June 01, 2005 - SPOTLIGHT CASE Cognitive Overload in the ICU Citation Text: Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTe…

  8. In Conversation With… Michael Cohen, RPh, MS, ScD (hon) | PSNet

    psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
    October 24, 2021 - In Conversation With… Michael Cohen, RPh, MS, ScD (hon) October 1, 2018  Citation Text: In Conversation With… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

  9. Anemia and Delayed Colon Cancer Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
    July 21, 2020 - SPOTLIGHT CASE Anemia and Delayed Colon Cancer Diagnosis Citation Text: Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …

  10. Patient Safety Events Involving Opioid Dose Stacking | PSNet

    psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
    July 08, 2022 - SPOTLIGHT CASE Patient Safety Events Involving Opioid Dose Stacking Citation Text: Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Cita…

  11. Chest Pain in a Rural Hospital | PSNet

    psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
    June 02, 2021 - SPOTLIGHT CASE Chest Pain in a Rural Hospital Citation Text: MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar Bi…

  12. Delirium or Dementia? | PSNet

    psnet.ahrq.gov/web-mm/delirium-or-dementia
    September 27, 2023 - SPOTLIGHT CASE Delirium or Dementia? Citation Text: Rudolph JL. Delirium or Dementia?. 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…

  13. Postdischarge Follow-Up Phone Call | PSNet

    psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
    May 19, 2021 - SPOTLIGHT CASE Postdischarge Follow-Up Phone Call Citation Text: Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Schol…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49831/psn-pdf
    June 01, 2018 - Chest Pain in a Rural Hospital June 1, 2018 MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/chest-pain-rural-hospital Case Objectives Recognize that a significant proportion of the Unites States population receives care in rural safety net emergency dep…

  15. Airway Obstruction during Anterior Cervical Spine Surgery | PSNet

    psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
    January 29, 2021 - Airway Obstruction during Anterior Cervical Spine Surgery Citation Text: Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: …

  16. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care | PSNet

    psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
    June 28, 2023 - SPOTLIGHT CASE A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care Citation Text: Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…

  17. 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…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72911/psn-pdf
    March 15, 2021 - The Impact of Communication on Medication Errors March 15, 2021 Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors The Case   A 93-year-old man with a history of chronic systolic heart failure…

  19. Antiseizure Medication Disorder | PSNet

    psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
    April 01, 2006 - SPOTLIGHT CASE Antiseizure Medication Disorder Citation Text: Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX En…

  20. 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…
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