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Showing results for "incident".

  1. psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
    June 01, 2016 - Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis
  2. psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
    January 07, 2015 - Although the case refers to the incident as an error, it is not clear that the events in the case meet
  3. psnet.ahrq.gov/web-mm/medical-devices-wild
    March 27, 2024 - where the fall occurred called a multidisciplinary "fall huddle" to reenact the circumstances of the incident
  4. psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
    March 25, 2020 - The Commentary By Christian Bohringer MD This incident describes a common type of adverse drug
  5. psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
    December 09, 2020 - References Figures Related Resources From the Same Author(s) Learning from incident
  6. psnet.ahrq.gov/web-mm/caution-interrupted
    October 01, 2016 - Interruptions Although this specific incident involves the interruption and distraction of a nurse,
  7. psnet.ahrq.gov/web-mm/mitigating-risk-intrahospital-transport-pediatric-patients-risk-physiologic-instability
    May 27, 2020 - The patient remained intubated, and was transported back to the PICU without incident, although still
  8. psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
    January 07, 2015 - The remainder of the CABG was completed without incident, and the patient was weaned off cardiopulmonary
  9. psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
    July 30, 2020 - Coronavirus Disease 2019 (COVID-19) and Diagnostic Error Citation Text: Desai AN, Romano PS. Coronavirus Disease 2019 (COVID-19) and Diagnostic Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73336/psn-pdf
    May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers May 26, 2021 Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers The Case  …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842919/psn-pdf
    February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis. February 1, 2023 Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis The Cases Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
  12. psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx Spotlight Respiratory Distress after Neck Surgery: Two Cases of Post-Operative Cervical Hematoma Source and Credits • This presentation is based on the January 2023 AHRQ WebM&M Spotlight Case o See the full article at https://…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49675/psn-pdf
    February 01, 2013 - Delay in Treatment: Failure to Contact Patient Leads to Significant Complications February 1, 2013 Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complicat…
  14. psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
    September 01, 2017 - Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks Citation Text: Martin DT, O’Leary D. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. …
  15. psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
    March 01, 2007 - The Role of the Patient in Improving Patient Safety Rosemary Gibson, MSc | March 1, 2007  Also Read a Conversation View more articles from the same authors. Citation Text: Gibson R. The Role of the Patient in Improving Patient Safety. PSNet [internet]. Rockville…
  16. psnet.ahrq.gov/web-mm/transfusion-overload
    September 23, 2020 - SPOTLIGHT CASE Transfusion Overload Citation Text: Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…
  17. psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
    March 15, 2023 - SPOTLIGHT CASE False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. Citation Text: Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …
  18. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
    December 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case December 2004 Discharge Fumbles Source and Credits This presentation is based on the Dec. 2004 AHRQ WebM&M Spotlight Case in Hospital Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Alan Forster, M…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49860/psn-pdf
    April 01, 2019 - Hip Fractures in Older Patients: the Case for Geriatrics Comanagement April 1, 2019 Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement The Case An 82-year-old man …
  20. psnet.ahrq.gov/web-mm/mark-my-tooth
    June 01, 2014 - Mark My Tooth Citation Text: Smith RA. Mark My Tooth. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS D…

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