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Showing results for "incidents".

9981. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72587/psn-pdf
      December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability December 23, 2020 Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm…

9982. Febrile Neutropenia and an Almost Fatal Medication Error | PSNet
      psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
      February 01, 2012 - Febrile Neutropenia and an Almost Fatal Medication Error Citation Text: Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: …

9983. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73999/psn-pdf
      October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room October 27, 2021 Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room …

9984. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49625/psn-pdf
      May 01, 2011 - Pocket Syringe Swap May 1, 2011 Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/pocket-syringe-swap The Case A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for postoperative pain management. Surgery proceeded uneventfully under…

9985. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room | PSNet
      psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
      February 01, 2019 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room Citation Text: Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. Rockville (MD): Agency for H…

9986. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49476/psn-pdf
      March 02, 2005 - Around the Block March 1, 2005 Minichiello T. Around the Block. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/around-block The Case A 77-year-old woman with multiple medical problems was admitted to the hospital for an elective knee replacement. The orthopedic surgeon, recognizing the risk of deep vein th…

9987. Wrong-side Bedside Paravertebral Block: Preventing the Preventable | PSNet
      psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
      August 10, 2019 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable Citation Text: Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy C…

9988. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49452/psn-pdf
      July 01, 2004 - Allergy to Holter July 1, 2004 Williams M. Allergy to Holter. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/allergy-holter The Case A 52-year-old man was admitted for palpitations and chest pain. As part of the evaluation, on hospital day 4 the patient was sent to the cardiac clinic to start a continuous …

9989. Double Dosing, by the Rules | PSNet
      psnet.ahrq.gov/web-mm/double-dosing-rules
      February 03, 2010 - Double Dosing, by the Rules Citation Text: Cohen H. Double Dosing, by the Rules. 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 tagg…

9990. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49765/psn-pdf
      August 21, 2016 - resume effectively than simple tasks.(13) Interestingly, surveys and retrospective accounts of adverse incidents

9991. Nothing Called Small Surgery | PSNet
      psnet.ahrq.gov/web-mm/nothing-called-small-surgery
      February 01, 2023 - guidelines recommending against the use of surgical gloves as tourniquets, following a report of 15 incidents

9992. Transfer Troubles | PSNet
      psnet.ahrq.gov/web-mm/transfer-troubles
      December 29, 2014 - Incidents during out-of-hospital patient transportation. Anaesth Intensive Care. 2006;34:228-236.

9993. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/862983/psn-pdf
      February 28, 2024 - professionals.18,19 Checklists and cognitive aids can be helpful during stressful life-threatening incidents

9994. Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities. | PSNet
      psnet.ahrq.gov/web-mm/challenging-case-multiple-suicide-attempts-complex-patient-psychiatric-comorbidities
      September 27, 2023 - Patients who die by suicide: a study of treatment patterns and patient safety incidents

9995. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867357/psn-pdf
      December 18, 2024 - Incidents relating to the intra-hospital transfer of critically ill patients.

9996. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73902/psn-pdf
      September 29, 2021 - Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome September 29, 2021 Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome. PSNet [internet]. 2021. https://psnet.ahrq.go…

9997. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers | PSNet
      psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
      January 07, 2022 - The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers Citation Text: Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…

9998. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon | PSNet
      psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
      January 29, 2021 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon Citation Text: Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…

9999. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_latex_allergies-slides.pdf
      January 01, 2022 - Spotlight Spotlight Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy Source and Credits • This presentation is based on the August 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by K…

10000. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. | PSNet
       psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
       August 14, 2024 - SPOTLIGHT CASE Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. Citation Text: Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…