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Showing results for "leads".

81. Semantically ambiguous language in the teaching operating room. | PSNet
    psnet.ahrq.gov/issue/semantically-ambiguous-language-teaching-operating-room
    November 11, 2020 - March 29, 2023 WebM&M Cases Saline Flush Leads to … Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads

82. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73875/psn-pdf
    October 27, 2021 - Human Factors Champions (nurses and clinical leads who received human factors training) observed teams … The majority of respondents felt better able to perform as team leads, supervise their teams, provide

83. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/836942/psn-pdf
    April 27, 2022 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in … Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in … https://psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper- medication-labeling … The Commentary By Robert Scott Kriss, DO https://psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling … https://psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling

84. Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning. | PSNet
    psnet.ahrq.gov/issue/proper-positioning-pharmacy-label-hospira-pca-vials-will-avoid-interference-scanning
    May 05, 2018 - Related Resources From the Same Author(s) Misprogramming PCA concentration leads … June 16, 2019 Misprogramming PCA concentration leads to dosing errors.

85. Human costs of training doctors. | PSNet
    psnet.ahrq.gov/issue/human-costs-training-doctors
    December 17, 2014 - December 17, 2014 Parkland knee surgery done by doctor in training leads to amputation … January 14, 2011 Parkland knee surgery done by doctor in training leads to amputation

86. Progress with preventing name confusion errors. | PSNet
    psnet.ahrq.gov/issue/progress-preventing-name-confusion-errors
    May 07, 2018 - Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared … August 8, 2018 Misprogramming PCA concentration leads to dosing errors.

87. Falls Prevention Awareness Week 2024 | PSNet
    psnet.ahrq.gov/curated-library/falls-prevention-awareness-week-2024
    September 07, 2019 - WebM&Ms (1) Spotlight Case CME/MOC Failure to Ensure Patient Safety Leads … CME/MOC Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.

88. When COVID-19 hit, many elderly were left to die. | PSNet
    psnet.ahrq.gov/issue/when-covid-19-hit-many-elderly-were-left-die
    June 24, 2020 - November 10, 2021 When medical care leads to harm—difficulty finding words: a teachable … February 10, 2015 Fear of Covid-19 leads other patients to decline critical treatment

89. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49752/psn-pdf
    January 01, 2016 - Inadvertent Use of More Potent Acid Leads to Burn January 1, 2016 Maibach HI. … Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. 2016. … https://psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn The Case A 31-year-old woman … https://psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn By the end of World War II

90. ISMP updates its list of drug name pairs with Tall man letters. | PSNet
    psnet.ahrq.gov/issue/ismp-updates-its-list-drug-name-pairs-tall-man-letters
    June 10, 2018 - From the Same Author(s) Electronic prescribing vulnerabilities: height and weight mix-up leads … May 7, 2018 Misprogramming PCA concentration leads to dosing errors.

91. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet
    psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
    March 25, 2020 - VF) may be induced by attempted cardioversion. 8 It is therefore very important to connect the ECG leads … This may take place in the electrophysiology lab or in the operating room where pacing via epicardial leads … team forgetting to check that the cardioverter/defibrillator had been hooked up correctly to the ECG leads … With this set-up, a separate pair of chest leads directly connected to the defibrillator is no longer … May 16, 2022 WebM&M Cases Saline Flush Leads to

92. Misidentification of alphanumeric symbols. | PSNet
    psnet.ahrq.gov/issue/misidentification-alphanumeric-symbols
    March 26, 2014 - September 14, 2022 WebM&M Cases Saline Flush Leads to … August 5, 2020 Incorrect use of smart infusion pump in the operating room (OR) leads

93. Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups? | PSNet
    psnet.ahrq.gov/issue/survey-lasa-drug-name-pairs-who-knows-whats-your-list-and-best-ways-prevent-mix-ups
    June 10, 2018 - November 3, 2021 The absence of a drug–disease interaction alert leads to a child's death … January 23, 2019 Misprogramming PCA concentration leads to dosing errors.

94. Misidentification of alphanumeric symbols in both handwritten and computer-generated information. | PSNet
    psnet.ahrq.gov/issue/misidentification-alphanumeric-symbols-both-handwritten-and-computer-generated-information
    May 07, 2018 - Related Resources From the Same Author(s) Failed check system for chemotherapy leads … June 10, 2018 Failed check system for chemotherapy leads to pharmacist's "no contest"

95. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/866520/psn-pdf
    August 14, 2024 - post-error slowing is not simply due to increased caution, but due to impaired cognitive processing, and leads

96. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/60903/psn-pdf
    March 15, 2023 - breaking-rules-understanding-non-compliance-policies-and-guidelines https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis

97. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/50373/psn-pdf
    September 25, 2019 - psnet.ahrq.gov/issue/2018-update-pediatric-medical-overuse-review https://psnet.ahrq.gov/issue/when-medical-care-leads-harm-difficulty-finding-words-teachable-moment

98. Results of survey on pediatric medication safety—part 1 and part 2. | PSNet
    psnet.ahrq.gov/issue/results-survey-pediatric-medication-safety-part-1-and-part-2
    November 16, 2015 - May 5, 2018 The absence of a drug–disease interaction alert leads to a child's death. … December 2, 2015 The absence of a drug–disease interaction alert leads to a child's death

99. Ten years after the IOM report: engaging residents in quality and patient safety by creating a house staff quality council. | PSNet
    psnet.ahrq.gov/issue/ten-years-after-iom-report-engaging-residents-quality-and-patient-safety-creating-house-staff
    December 27, 2014 - December 27, 2014 An anesthesiology department leads culture change at a hospital system … March 2, 2011 An anesthesiology department leads culture change at a hospital system

100. The role of housestaff in implementing medication reconciliation on admission at an academic medical center. | PSNet
     psnet.ahrq.gov/issue/role-housestaff-implementing-medication-reconciliation-admission-academic-medical-center
     March 30, 2011 - March 30, 2011 An anesthesiology department leads culture change at a hospital system … March 2, 2011 An anesthesiology department leads culture change at a hospital system