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Showing results for "incident".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49839/psn-pdf
    August 01, 2018 - Mixup Beyond the Medication Label August 1, 2018 Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label The Case An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another hospi…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49781/psn-pdf
    January 01, 2017 - Hazards of Loading Doses January 1, 2017 Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hazards-loading-doses The Case A 40-year-old woman was recently discharged after a prolonged hospitalization for seizures and a cardiac arrest. Two days after discharg…

  3. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.230_slideshow.ppt
    December 01, 2010 - Spotlight Case July 2008 Spotlight Case The Forgotten Turn * * Source and Credits This presentation is based on the December 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Susan Barbour, RN, FNP, University of California San Francisco …

  4. Published Comment and Response: Comparing the USPSTF and GRADE Approaches to Recommendations | United States Preventive Services Taskforce

    www.uspreventiveservicestaskforce.org/uspstf/published-comment-and-response-comparing-uspstf-and-grade-approaches-recommendations
    February 01, 2014 - Published Comment and Response: Comparing the USPSTF and GRADE Approaches to Recommendations Share to Facebook Share to X Share to WhatsApp Share to Email Print First published as a Letter to the Editor in  Annals of Internal Medicine  151(5)…

  5. Utilizing Health Information Technology to Improve Health Care Quality | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/utilizing-health-information-technology-improve-health-care-quality
    January 01, 2023 - Utilizing Health Information Technology to Improve Health Care Quality Project Final Report ( PDF , 395.03 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent t…

  6. Making Healthcare Safer Practices: 14. Delirium (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/delirium-1.pdf
    March 01, 2020 - Making Healthcare Safer Practices: 14. Delirium Delirium 14-1 14. Delirium Authors: Lynn Hoffman M.A., M.P.H., Aline Holmes D.N.P., R.N., Jennifer Riggs, Ph.D., R.N., and Stephanie Schneiderman, M.P.P. Introduction Patient safety research and quality improvement efforts have been underway in the delirium harm …

  7. Serologic Screening for Genital Herpes: An Updated Evidence Report and Systematic Review for the USPSTF (pdf file)

    www.uspreventiveservicestaskforce.org/home/getfilebytoken/aHpXYasjc3n6zhaTtoWMwK
    August 01, 2016 - Serologic Screening for Genital Herpes: An Updated Evidence Report and Systematic Review for the USPSTF Copyright 2016 American Medical Association. All rights reserved. Serologic Screening for Genital Herpes An Updated Evidence Report and Systematic Review for the US Preventive Services Task Force Cynthia Feltner, …

  8. Tx-For-Localized-Prostate-Cancer Surveillanceassesment 20120614 (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/tx-for-localized-prostate-cancer_surveillanceassesment_20120614.pdf
    May 01, 2012 - CER #13: Comparative Effectiveness of Therapies for Clinically Localized Prostate Cancer Original release date: February 2008 Surveillance Report: May 2012 Key Findings: • The PIVOT trial was identified, making many of the existing key conclusions out of date. • Key questions 1, 2, and 4 were found t…

  9. Tx-For-Localized-Prostate-Cancer Surveillanceassesment 20120614 (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/tx-for-localized-prostate-cancer_surveillanceassesment_20120614.pdf
    May 01, 2012 - CER #13: Comparative Effectiveness of Therapies for Clinically Localized Prostate Cancer Original release date: February 2008 Surveillance Report: May 2012 Key Findings: • The PIVOT trial was identified, making many of the existing key conclusions out of date. • Key questions 1, 2, and 4 were found t…

  10. Standardizing Medication Error Event Reporting in the U.S. Department of Defense (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
    March 01, 2004 - user then can select a single error from the spreadsheet and view all the pertinent details from the incident

  11. Advancing Diagnostic Equity Through Clinician Engagement, Community Partnerships, and Connected Care (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/topics/advancing-diagnostic-equity.pdf
    November 15, 2022 - This approach would require modifying current systems used to identify patient safety events (e.g., incident

  12. Dropping the Ball Despite an Integrated EMR | PSNet

    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

  13. Medical Devices in the "Wild" | PSNet

    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

  14. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability | PSNet

    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

  15. One Bronchoscopy, Two Errors | PSNet

    psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
    December 09, 2020 - References Figures Related Resources From the Same Author(s) Learning from incident

  16. Caution, Interrupted | PSNet

    psnet.ahrq.gov/web-mm/caution-interrupted
    October 01, 2016 - Interruptions Although this specific incident involves the interruption and distraction of a nurse,

  17. No BP During NIBP | PSNet

    psnet.ahrq.gov/web-mm/no-bp-during-nibp
    March 01, 2011 - Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and

  18. Danger in Disruption | PSNet

    psnet.ahrq.gov/web-mm/danger-disruption
    July 29, 2020 - The child was apneic briefly but recovered without incident.

  19. Discontinued Medications: Are They Really Discontinued? | PSNet

    psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
    January 05, 2017 - July 22, 2015 Exploring health care professionals' perceptions of incidents and incident

  20. The Context Is the Intervention | PSNet

    psnet.ahrq.gov/perspective/context-intervention
    August 05, 2020 - Patient Safety September 1, 2013 Perspective Incident
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