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Showing results for "initiatives".

  1. Tacit Handover, Overt Mishap | PSNet

    psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
    August 01, 2006 - Tacit Handover, Overt Mishap Citation Text: Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

  2. The Perils of Contrast Media | PSNet

    psnet.ahrq.gov/web-mm/perils-contrast-media
    March 01, 2007 - SPOTLIGHT CASE The Perils of Contrast Media Citation Text: Sadat U, Solomon R. The Perils of Contrast Media. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX En…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33637/psn-pdf
    August 01, 2006 - In Conversation with...Lucian Leape, MD August 1, 2006 In Conversation with..Lucian Leape, MD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withlucian-leape-md Dr. Robert Wachter, Editor, AHRQ WebM&M: What kind of career did you fashion for yourself prior to getting involved in safety an…

  4. Reaction to Dye | PSNet

    psnet.ahrq.gov/web-mm/reaction-dye
    March 01, 2007 - Reaction to Dye Citation Text: Cohan R. Reaction to Dye. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  5. One Dose, Two Errors | PSNet

    psnet.ahrq.gov/web-mm/one-dose-two-errors
    September 29, 2017 - One Dose, Two Errors Citation Text: Filice GA. One Dose, Two Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

  6. Discharged with IV antibiotics: When issues arise, who manages the complications? | PSNet

    psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
    October 10, 2017 - SPOTLIGHT CASE Discharged with IV antibiotics: When issues arise, who manages the complications? Citation Text: Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…

  7. Who Nose Where the Airway Is? | PSNet

    psnet.ahrq.gov/web-mm/who-nose-where-airway
    May 01, 2016 - Who Nose Where the Airway Is? Citation Text: Lee CR. Who Nose Where the Airway Is?. 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 t…

  8. The Hidden Danger of Unseen Intravenous Catheters | PSNet

    psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
    October 04, 2023 - The Hidden Danger of Unseen Intravenous Catheters Citation Text: Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google S…

  9. Inadequate Preanesthetic Evaluation, Airway Trouble | PSNet

    psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
    November 01, 2023 - Inadequate Preanesthetic Evaluation, Airway Trouble Citation Text: Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854897/psn-pdf
    October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose October 31, 2023 Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/weight-and-…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33769/psn-pdf
    June 01, 2014 - Patient Advocacy in Patient Safety: Have Things Changed? June 1, 2014 Haskell H. Patient Advocacy in Patient Safety: Have Things Changed? PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed Perspective In 1981, a cancer patient named Paula Carroll founded…

  12. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
    January 01, 2021 - Spotlight Spotlight Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough Source and Credits • This presentation is based on the April 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Verna Gibbs, MD o AHRQ W…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33877/psn-pdf
    April 01, 2019 - In Conversation With… Timothy B. McDonald, MD, JD April 1, 2019 In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd Editor's note: Dr. McDonald is President of the Center for Open and Honest Communication at the MedStar…

  14. In Conversation With... James P. Bagian, MD, PE | PSNet

    psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
    February 26, 2025 - In Conversation With... James P. Bagian, MD, PE December 1, 2016  Citation Text: In Conversation With.. James P. Bagian, MD, PE. PSNet [internet]. 2016.In Conversation With... James P. Bagian, MD, PE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research a…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73456/psn-pdf
    June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia June 30, 2021 Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…

  16. In Conversation with...Albert Wu, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
    February 26, 2025 - In Conversation with...Albert Wu, MD, MPH July 1, 2008  Citation Text: In Conversation with..Albert Wu, MD, MPH. PSNet [internet]. 2008.In Conversation with...Albert Wu, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74251/psn-pdf
    January 26, 2022 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest January 26, 2022 Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. 2022. https…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853773/psn-pdf
    September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side. September 27, 2023 Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side The Case A first-year orthopedic surgery resident was consulted…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49712/psn-pdf
    June 01, 2014 - May I Have Another?—Medication Error June 1, 2014 Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error The Case A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a pharmacology-tra…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838855/psn-pdf
    October 27, 2022 - False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. October 27, 2022 Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/false-assumptions-resul…
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