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Total Results: 3,178 records

Showing results for "led".

2841. Standard Deviations | PSNet
      psnet.ahrq.gov/web-mm/standard-deviations
      January 01, 2006 - Once this patient begins to feel better, the personality factors that led to his homelessness and drug

2842. In Conversation With… Christine Cassel, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-christine-cassel-md
      February 26, 2025 - That led to the decision to refer to them now as serious reportable events.

2843. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49669/psn-pdf
      November 01, 2012 - modern guidelines (6,9), the clinicians might have avoided giving the second unit, which seems to have led

2844. In Conversation with...Sorrel King | PSNet
      psnet.ahrq.gov/perspective/conversation-withsorrel-king
      March 01, 2007 - Robert Wachter, Editor, AHRQ WebM&M: What led to your partnership with Hopkins?

2845. One Dose, Two Errors | PSNet
      psnet.ahrq.gov/web-mm/one-dose-two-errors
      September 29, 2017 - Didactic education might have led the resident or the ID specialist to use an echinocandin instead of

2846. The Safety Challenges of Supervision and Night Coverage in Academic Residency | PSNet
      psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
      February 21, 2024 - night staffing, poorly calibrated trainee autonomy, and cultural hierarchy barriers that ultimately led

2847. Missed Patient Assignment: Is Anyone There? | PSNet
      psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
      September 01, 2017 - The concern for this neglected patient and the potential for similar events in the future led to a root

2848. Failure to Latch | PSNet
      psnet.ahrq.gov/web-mm/failure-latch
      November 27, 2012 - This family's insistence that the infant's breastfeeding difficulties be addressed ultimately led to

2849. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient | PSNet
      psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overdose-pediatric-patient
      October 04, 2023 - therapy. 1 For example, studies have shown that rectal administration of acetaminophen during surgery led

2850. Burnout | PSNet
      psnet.ahrq.gov/primer/burnout
      November 20, 2024 - Institute for Healthcare Improvement launched a National Steering Committee for Patient Safety co-led

2851. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose | PSNet
      psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
      March 15, 2023 - In this case, four significant problems led to the alignment of the “holes” in the “slices” of the Swiss

2852. Impact of System Failures on Healthcare Workers | PSNet
      psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
      August 30, 2023 - The news of Vaught’s conviction led healthcare professionals to reflect on the impact that the conviction

2853. The Inside of a Time Out | PSNet
      psnet.ahrq.gov/web-mm/inside-time-out
      March 01, 2004 - Best practices suggest that the time out be led by the physician responsible for performing the procedure

2854. Check Twice, Transport Once | PSNet
      psnet.ahrq.gov/web-mm/check-twice-transport-once
      March 15, 2023 - the cases described above, the incorrect patient was transported for a procedure or surgery, which led

2855. Watch the Warfarin! | PSNet
      psnet.ahrq.gov/web-mm/watch-warfarin
      December 01, 2013 - in this case was fortunate in that his INR, though approaching dangerously high levels, had not yet led

2856. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. | PSNet
      psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
      May 01, 2005 - Cancer: Patient Catches Medical Error May 1, 2013 The impact of pharmacists-led

2857. Techno Trip | PSNet
      psnet.ahrq.gov/web-mm/techno-trip
      May 01, 2005 - Repeated exposure to these problems led workers to devise relatively straightforward solutions, such

2858. In Conversation With… Urmimala Sarkar, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
      August 22, 2014 - So that has led to a lag in focusing on outpatient safety. … If there were an ambulatory missed opportunity that led to a subsequent hospitalization that would be

2859. How Does Health Care Simulation Affect Patient Care? | PSNet
      psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
      August 01, 2018 - authors concluded that well-constructed simulation programs for physicians, nurses, and pharmacists led … There's a national initiative led by some societies and foundations to enhance clinicians' training in

2860. Beyond the Hospital: the New Frontier of Patient Safety | PSNet
      psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
      August 01, 2014 - So that has led to a lag in focusing on outpatient safety. … If there were an ambulatory missed opportunity that led to a subsequent hospitalization that would be