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Showing results for "integrated".

4521. 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…

4522. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33860/psn-pdf
      June 01, 2018 - Safety Considerations in Building a Point-of-Care Ultrasound Program June 1, 2018 Moore C. Safety Considerations in Building a Point-of-Care Ultrasound Program. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program Perspective At the American Colle…

4523. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49551/psn-pdf
      December 01, 2007 - Too Hot For Comfort December 1, 2007 Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/too-hot-comfort The Case A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV antibiotics via a peripheral line in the left antec…

4524. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49745/psn-pdf
      October 01, 2015 - Amphotericin Toxicity October 1, 2015 Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/amphotericin-toxicity The Case A 42-year-old woman status-post left pneumonectomy for aspergilloma was being treated with oral posaconazole for residual fungal disease. She present…

4525. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49487/psn-pdf
      August 21, 2005 - Surprise Wire August 21, 2005 Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/surprise-wire The Case A 39-year-old man with a history of liver disease presented to the emergency department (ED) with gastrointestinal bleeding and altered mental status. Due to his clinic…

4526. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49832/psn-pdf
      June 01, 2018 - Febrile Neutropenia and an Almost Fatal Medication Error June 1, 2018 Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error The Case A 33-year-old woman with recently diagnosed acute …

4527. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience | PSNet
      psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
      December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005  View more articles from the same authors. Citation Text: Conway JB, Weingart SN. Organizational Change…

4528. Medication Errors and Adverse Drug Events | PSNet
      psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
      December 15, 2024 - Medication Errors and Adverse Drug Events Citation Text: Medication Errors and Adverse Drug Events. 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…

4529. Lethal Cap | PSNet
      psnet.ahrq.gov/web-mm/lethal-cap
      December 19, 2018 - Lethal Cap Citation Text: Schillinger D. Lethal Cap. 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 Do…

4530. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849660/psn-pdf
      May 31, 2023 - Strategies to Improve Organizational Health Literacy. May 31, 2023 Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy Background Health literacy is important at both the personal …

4531. 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 …

4532. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49695/psn-pdf
      October 01, 2013 - Finding Fault With the Default Alert October 1, 2013 Baysari M. Finding Fault With the Default Alert. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/finding-fault-default-alert The Case A 33-year-old man with known refractory epilepsy and developmental delay was admitted to the hospital after experiencing …

4533. The Forgotten Drip | PSNet
      psnet.ahrq.gov/web-mm/forgotten-drip
      April 01, 2014 - The Forgotten Drip Citation Text: Josephson AS. The Forgotten Drip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…

4534. Amended Lab Results: Communication Slip | PSNet
      psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
      September 26, 2012 - Amended Lab Results: Communication Slip Citation Text: Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

4535. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33846/psn-pdf
      November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety November 1, 2017 Rozenblum R, Bates DW. The Role of Patient-facing Technologies to Empower Patients and Improve Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-imp…

4536. Secured But Not Always Safe | PSNet
      psnet.ahrq.gov/web-mm/secured-not-always-safe
      October 01, 2015 - Secured But Not Always Safe Citation Text: Jahr JS, Hosseini P. Secured But Not Always Safe. 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 XML EndNote 7 XML …

4537. 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, …

4538. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867655/psn-pdf
      February 26, 2025 - Learning Health Systems for Patient Safety February 26, 2025 Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety Despite an observable decrease in adverse events in health care over time, rat…

4539. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33779/psn-pdf
      March 01, 2015 - Handoffs and Transitions January 22, 2014 Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/handoffs-and-transitions Annual Perspective 2014 Despite recent efforts to promote clinical integration, the United States health care system remains highly fragmented. From it…

4540. In Conversation With… David Urbach, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-david-urbach-md-msc
      June 12, 2019 - The bodies that mandated the use of checklists didn't do it because they felt it integrated nurses and