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Showing results for "initiative".

  1. In Conversation with… Michael Cohen, RPh, MS, ScD (hon) | PSNet

    psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
    April 01, 2006 - In Conversation with… Michael Cohen, RPh, MS, ScD (hon) April 1, 2006  Also Read an Essay 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 …

  2. Maternal Safety | PSNet

    psnet.ahrq.gov/primer/maternal-safety
    January 10, 2024 - Maternal Safety Citation Text: Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…

  3. In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm | PSNet

    psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
    June 14, 2023 - Sarah Mossburg: It’s really important to get leadership support for this kind of initiative.

  4. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience | PSNet

    psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
    July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience Karen Frush, MD | May 1, 2005  View more articles from the same authors. Citation Text: Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33638/psn-pdf
    August 01, 2006 - Getting Into Patient Safety: A Personal Story August 1, 2006 Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/getting-patient-safety-personal-story Perspective My journey into patient safety began in 1972. It was born of serendipity enabled by the…

  6. Discharged Blindly | PSNet

    psnet.ahrq.gov/web-mm/discharged-blindly
    October 26, 2022 - Discharged Blindly Citation Text: Iezzoni LI. Discharged Blindly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…

  7. In Conversation With… Lorri Zipperer, MA | PSNet

    psnet.ahrq.gov/perspective/conversation-lorri-zipperer-ma
    February 26, 2025 - In Conversation With… Lorri Zipperer, MA November 1, 2015  Citation Text: In Conversation With… Lorri Zipperer, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation For…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49574/psn-pdf
    November 01, 2008 - A Mid-Summer Fog November 1, 2008 Braddock CH. A Mid-Summer Fog. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/mid-summer-fog The Case A 33-year-old woman with type I diabetes mellitus was admitted for symptoms of left flank pain, dysuria, and emesis, concerning for pyelonephritis. The patient was taking …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33689/psn-pdf
    October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety October 1, 2009 Wachter R. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety Perspective …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33825/psn-pdf
    January 01, 2017 - Rethinking Root Cause Analysis January 1, 2016 Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis Annual Perspective 2016 Introduction Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…

  11. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
    June 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case June 2005 Getting to the Root of the Matter Source and Credits This presentation is based on the June 2005 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Scott Flanders, MD; Sa…

  12. Mark My Tooth | PSNet

    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…

  13. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
    May 01, 2012 - Spotlight Case July 2008 Spotlight Case The Perils of Cross Coverage * * Source and Credits This presentation is based on the May 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49812/psn-pdf
    November 01, 2017 - Specimen Almost Lost November 1, 2017 Hehe YK. Specimen Almost Lost. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/specimen-almost-lost The Case A 29-year-old woman presented to the hospital with a rash that had spread across her legs and abdomen. She was admitted to the medicine service for further evalu…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49631/psn-pdf
    July 01, 2011 - Patient Safety and Adherence to Self-Administered Medications July 1, 2011 Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications The Case A 30-year-o…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49650/psn-pdf
    March 01, 2012 - Turn the Other Cheek March 1, 2012 Starling J. Turn the Other Cheek. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/turn-other-cheek The Case A 56-year-old man underwent two skin biopsies to evaluate clinically concerning lesions. The first biopsy was diagnostic for squamous cell carcinoma (SCC) and docume…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49463/psn-pdf
    October 14, 2004 - Moved Too Soon October 1, 2004 Lindenauer PK. Moved Too Soon. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/moved-too-soon The Case A 67-year-old man was admitted to a general hospital ward after undergoing a laminectomy. Two hours after arriving, while the patient was still groggy from anesthesia, a nurs…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60653/psn-pdf
    April 25, 2020 - Health Care Delivery and Pharmacists During the COVID- 19 Pandemic June 29, 2020 Dopp AL, Fitall E, Hall KK, et al. Health Care Delivery and Pharmacists During the COVID-19 Pandemic. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic Medication…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60547/psn-pdf
    May 28, 2020 - The Role of the FDA in Ensuring Device Safety May 28, 2020 Fitall E, Hall KK, Gale B. The Role of the FDA in Ensuring Device Safety . PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety Introduction The Food and Drug Administration (FDA) plays a critical role in ensuring the …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49814/psn-pdf
    December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation Mishap December 1, 2017 Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap The Case A 63-year-old man with a history of coronary…
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