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6841. Recognizing Excellence in Diagnosis. | PSNet
      psnet.ahrq.gov/issue/recognizing-excellence-diagnosis
      November 03, 2023 - Multi-use Website Recognizing Excellence in Diagnosis. Citation Text: Recognizing Excellence in Diagnosis. The Leapfrog Group. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy…

6842. Hospital-Acquired Condition Reduction Program (HACRP). | PSNet
      psnet.ahrq.gov/issue/hospital-acquired-condition-hac-reduction-program
      May 26, 2021 - Multi-use Website Hospital-Acquired Condition Reduction Program (HACRP). Citation Text: Hospital-Acquired Condition Reduction Program (HACRP). QualityNet. Centers for Medicare and Medicaid Services. Copy Citation Save Save to your library Print Download …

6843. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49800/psn-pdf
      July 01, 2017 - The Hidden Harms of Hand Sanitizer July 1, 2017 Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer The Case A 57-year-old woman with a history of alcohol abuse and severe depression was admitted to the hospital for community-acquired pn…

6844. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33817/psn-pdf
      October 01, 2016 - Health Care Data Science for Quality Improvement and Patient Safety October 1, 2016 Rajkomar A. Health Care Data Science for Quality Improvement and Patient Safety. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety Perspective Background Ha…

6845. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49603/psn-pdf
      June 01, 2010 - Fatal Error in Neonate: Does "Just Culture" Provide an Answer? June 1, 2010 Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer Case Objectives Describe the just culture approach to in…

6846. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.248_slideshow.ppt
      September 01, 2011 - Spotlight Case July 2008 Spotlight Case The Safety and Quality of Long Term Care * * Source and Credits This presentation is based on the September 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Amy A. Vogelsmeier, PhD, RN, GCNS-BC, Uni…

6847. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33586/psn-pdf
      December 15, 2024 - Alert Fatigue December 15, 2024 Alert Fatigue. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/alert-fatigue 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. Bac…

6848. Patient Safety in Medical, Nursing, and Other Clinical Education | PSNet
      psnet.ahrq.gov/perspective/patient-safety-medical-nursing-and-other-clinical-education
      January 31, 2020 - Annual Perspective Patient Safety in Medical, Nursing, and Other Clinical Education March 16, 2020  View more articles from the same authors. Citation Text: Howley LD, Hall KK, Fitall E. Patient Safety in Medical, Nursing, and Other Clinical Education . PSNe…

6849. A Fumbled Handoff to Inpatient Rehab | PSNet
      psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
      December 21, 2018 - A Fumbled Handoff to Inpatient Rehab Citation Text: Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3…

6850. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49638/psn-pdf
      January 01, 2012 - Communication Failure—Who's in Charge? October 1, 2011 Fackler J, Schwartz JM. Communication Failure—Who's in Charge? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/communication-failure-whos-charge The Case A 20-month-old boy was admitted to the intensive care unit (ICU) following a Fontan surgical procedu…

6851. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49794/psn-pdf
      May 01, 2017 - Communication Error in a Closed ICU May 1, 2017 Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/communication-error-closed-icu The Case A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney transplant), co…

6852. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50756/psn-pdf
      December 18, 2019 - A Mistaken Dose of Naloxone? December 18, 2019 Cutler E, Gunawardena D. A Mistaken Dose of Naloxone?. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/mistaken-dose-naloxone The Case A 55-year-old man with widely metastatic gastric cancer presented to his oncologist's office for a follow-up appointment. He h…

6853. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33697/psn-pdf
      June 01, 2010 - What Do We Know About Emergency Department Safety? June 1, 2010 Sklar DP, Crandall CS. What Do We Know About Emergency Department Safety? PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety Perspective Emergency medicine has evolved from a location, with var…

6854. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49458/psn-pdf
      September 01, 2004 - Poor Prognosis September 1, 2004 Lamont EB. Poor Prognosis. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/poor-prognosis Case Objectives Understand the current limitations of physicians' ability to provide prognoses. List the variables that can be used to guide treatment decisions and prognostication in e…

6855. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50612/psn-pdf
      October 30, 2019 - The Safety Challenges of Supervision and Night Coverage in Academic Residency October 30, 2019 Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency The Case…

6856. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49728/psn-pdf
      March 01, 2015 - Medication Mix-Up: From Bad to Worse March 1, 2015 Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/medication-mix-bad-worse The Case A 69-year-old man with chronic kidney disease and essential hypertension was admitted to the hospital with chest …

6857. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49778/psn-pdf
      December 01, 2016 - One Dose, Two Errors December 1, 2016 Filice GA. One Dose, Two Errors. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/one-dose-two-errors The Case A 65-year-old woman was admitted to the intensive care unit (ICU) with severe sepsis and respiratory failure secondary to community-acquired pneumonia. The pati…

6858. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49462/psn-pdf
      October 01, 2004 - Thin Air October 1, 2004 Gaba DM. Thin Air. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/thin-air Case Objectives Identify the gas-specific non-interchangeable connectors used for bulk gas supply outlets in hospitals. Define forcing function, both in engineered safety devices and in human procedures. R…

6859. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49490/psn-pdf
      September 01, 2005 - The Wrong Channel September 1, 2005 Gosbee JW. The Wrong Channel . PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/wrong-channel The Case A 28-year-old woman in labor began receiving treatment with magnesium sulfate for preeclampsia. Initial dosing started at 50 mL/hour using a multi-channel medication pump…

6860. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49749/psn-pdf
      December 01, 2015 - Hyperglycemia and Switching to Subcutaneous Insulin December 1, 2015 Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin The Case A 47-year-old man with type 2 diabetes was admitted to the hospita…