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Showing results for "institution".

4641. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49460/psn-pdf
      September 01, 2004 - Security Lapse September 1, 2004 Mason D. Security Lapse. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/security-lapse The Case A medical student learned that the hospital's radiology image library was accessible throughout the university's computer system, meaning that patient x-rays could be viewed in d…

4642. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33713/psn-pdf
      June 01, 2011 - The Safety of Medical Devices June 1, 2011 Nemeth CP. The Safety of Medical Devices. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/safety-medical-devices Perspective Edward Tenner is right. Technology does have reverberations, including unintended consequences, or "revenge effects."(1) While such dra…

4643. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.251_slideshow.ppt
      October 01, 2011 - Spotlight Case [MONTH] 2003 Spotlight Case Mobility Lost in the ICU * * Source and Credits This presentation is based on the October 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jim Smith, PT, DPT, MA; Associate Professor of Physical …

4644. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49692/psn-pdf
      September 01, 2013 - A Picture Speaks 1000 Words September 1, 2013 Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/picture-speaks-1000-words The Case A 62-year-old man with a past medical history of hypertension, hyperlipidemia, and type A aortic dissection repair presented with chest p…

4645. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33655/psn-pdf
      August 01, 2007 - The PeaceHealth Governance Journey in Support of Quality and Safety August 1, 2007 Haughom JL. The PeaceHealth Governance Journey in Support of Quality and Safety. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety Perspective In recent years, the…

4646. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33641/psn-pdf
      November 01, 2006 - Human Factors Engineering Can Teach You How to Be Surprised Again November 1, 2006 Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Again. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again Perspective Certain phrases ar…

4647. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
      February 01, 2017 - PowerPoint Presentation Spotlight The Hazards of Distraction: Ticking All the EHR Boxes * Source and Credits This presentation is based on the February 2017 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Anthony C. Easty, PhD, Adjunct Pr…

4648. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49511/psn-pdf
      May 01, 2006 - Citrate Mix-Up May 1, 2006 Weber RJ. Citrate Mix-Up. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/citrate-mix The Case A 36-year-old woman with multiple sclerosis, diabetes, and chronic renal failure was transferred from a skilled nursing facility (SNF) to the hospital for treatment of an infection. On a…

4649. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33755/psn-pdf
      September 01, 2013 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety September 1, 2013 Singer SJ. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/what-weve-learned-ab…

4650. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.257_slideshow.ppt
      December 01, 2011 - Spotlight Case July 2008 Spotlight Case Order Interrupted by Text: Multitasking Mishap * * Source and Credits This presentation is based on the December 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John Halamka, MD, MS, Chief Informa…

4651. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33606/psn-pdf
      December 15, 2024 - Opioid Safety December 15, 2024 Opioid Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/opioid-safety 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…

4652. High Reliability | PSNet
      psnet.ahrq.gov/primer/high-reliability
      January 29, 2020 - High Reliability Citation Text: High Reliability. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Downl…

4653. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50844/psn-pdf
      January 29, 2020 - Improving Patient Safety and Team Communication through Daily Huddles January 29, 2020 Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. 2020. https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles Background Communicat…

4654. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73905/psn-pdf
      October 06, 2021 - Health Equity and Maternal Health October 6, 2021 Tully K, Stuebe AM, Gibson A, et al. Health Equity and Maternal Health. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/health-equity-and-maternal-health Redefining Maternal Safety Maternal safety refers to the safety of a person during pregnancy, childb…

4655. Triggers and Trigger Tools | PSNet
      psnet.ahrq.gov/primer/triggers-and-trigger-tools
      September 15, 2024 - Triggers and Trigger Tools Citation Text: Triggers and Trigger Tools. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…

4656. Human Factors Engineering | PSNet
      psnet.ahrq.gov/primer/human-factors-engineering
      December 15, 2024 - Human Factors Engineering Citation Text: Human Factors Engineering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…

4657. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33854/psn-pdf
      March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety March 1, 2018 Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety Perspective Errors in hospitals remain a major cause of death.(1…

4658. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement | PSNet
      psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
      July 01, 2004 - Hip Fractures in Older Patients: the Case for Geriatrics Comanagement Citation Text: Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy…

4659. Diagnostic Delay in the Emergency Department | PSNet
      psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
      September 18, 2024 - SPOTLIGHT CASE Diagnostic Delay in the Emergency Department Citation Text: Marshall K, Singh H. Diagnostic Delay in the Emergency Department. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format:…

4660. Hidden Heparins: HIT Happens | PSNet
      psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
      March 27, 2024 - SPOTLIGHT CASE Hidden Heparins: HIT Happens Citation Text: Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3…