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Total Results: 5,529 records

Showing results for "institution".

4661. Is the Admission Drug Dose Too Low? | PSNet
      psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
      September 01, 2011 - Is the Admission Drug Dose Too Low? Citation Text: Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low?. 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…

4662. Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
      January 01, 2020 - Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx Spotlight Premature Closure: Was it Just Syncope? Source and Credits • This presentation is based on the November 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit i…

4663. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.323_slideshow.ppt
      May 01, 2014 - PowerPoint Presentation Spotlight Medication Reconciliation With a Twist (or Dare We Say, a Patch?) This presentation is based on the May 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Janice Kwan, MD, Department of Medicine, University of Tor…

4664. Check the Anesthesia Machine | PSNet
      psnet.ahrq.gov/web-mm/check-anesthesia-machine
      August 01, 2006 - Check the Anesthesia Machine Citation Text: Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…

4665. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49422/psn-pdf
      November 01, 2003 - 40 of K November 1, 2003 Lesar TS. 40 of K. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/40-k The Case An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…

4666. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50842/psn-pdf
      January 29, 2020 - Patient Identification Errors: A Systems Challenge January 29, 2020 Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge The Cases The following four events involving five patients all involved…

4667. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50701/psn-pdf
      November 26, 2019 - In Conversation With... Heidi Wald, MD November 26, 2019 In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-heidi-wald-md Editor’s note: Dr. Wald, MD, MSPH, is the Chief Quality and Safety Officer at SCL Health in Denver, CO. She has previously served as …

4668. Benefits vs. Risks of Intraosseous Vascular Access | PSNet
      psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
      September 01, 2005 - Benefits vs. Risks of Intraosseous Vascular Access Citation Text: Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Go…

4669. Specimen Almost Lost | PSNet
      psnet.ahrq.gov/web-mm/specimen-almost-lost
      September 21, 2022 - Specimen Almost Lost Citation Text: Hehe YK. Specimen Almost Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…

4670. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49731/psn-pdf
      April 01, 2015 - Fire in the Hole!—An OR Fire April 1, 2015 Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fire-hole-or-fire The Case A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection for a biopsy-proven adenocarcinom…

4671. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.140_slideshow.ppt
      December 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case December 2006 Hidden Heparins: HIT Happens Source and Credits This presentation is based on the December 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Patrick F. Fogarty,…

4672. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49707/psn-pdf
      April 01, 2014 - CYP450 Drugs: Expect the Unexpected April 1, 2014 Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected The Case A 42-year-old man with acquired immunodeficiency syndrome (AIDS) (CD4 count 198), hip dystocia, and generalized anxiety …

4673. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-473
      March 25, 2025 - March 5, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports, …

4674. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression | PSNet
      psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
      May 26, 2021 - Several important policy changes were made at an institution level in response to this fatal event, including

4675. Errors and Near Misses: What Health Care Could Learn From Aviation | PSNet
      psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
      September 01, 2006 - Everybody learned from a particular person or an institution—which led to, you know, this is the Penn

4676. Rediscovering the Power of the Surgical M&M Conference: The M M Matrix | PSNet
      psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
      September 01, 2007 - As a teaching institution, we have to end up teaching surgeons and doctors, and we have to be able to

4677. Falling Through the Crack (in the Bedrails) | PSNet
      psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
      February 19, 2020 - The institution wondered what steps could be taken to prevent a similar incident in the future, as well

4678. The Role of Health Literacy in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
      March 22, 2009 - The Role of Health Literacy in Patient Safety Michael S. Wolf, PhD, MPH; Stacy Cooper Bailey, MPH | March 1, 2009  Also Read a Conversation View more articles from the same authors. Citation Text: Wolf MS, Bailey SC. The Role of Health Literacy in Patient Safety…

4679. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-447
      July 10, 2024 - a transplant surgeon encountered while trying to discuss contributors to troubling patterns at his institution

4680. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853774/psn-pdf
      September 27, 2023 - Criteria vary by institution, but patients are most often identified at triage using specific clinical