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Total Results: 3,344 records

Showing results for "led".

2941. 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

2942. Harm From Alarm Fatigue | PSNet
      psnet.ahrq.gov/web-mm/harm-alarm-fatigue
      February 14, 2018 - Similar to the case described here, under-counting of heart rate due to low-voltage QRS complexes led

2943. Tacit Handover, Overt Mishap | PSNet
      psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
      August 01, 2006 - issue to discuss is the handoff, the transition of care between providers, which clearly was subpar and led

2944. Breakage of a PICC Line | PSNet
      psnet.ahrq.gov/web-mm/breakage-picc-line
      June 21, 2023 - the site underwent repeated sterile dressings and had been in place for more than a month might have led

2945. Perils in Diagnosing a Stroke | PSNet
      psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
      August 15, 2017 - Target: Stroke," which also emphasizes fast administration of IV thrombolytics.( 8 ) These factors have led

2946. 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

2947. Check the Wristband | PSNet
      psnet.ahrq.gov/web-mm/check-wristband
      August 03, 2009 - the extent to which patients can be distracted from understanding or retaining new information has led

2948. 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

2949. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49552/psn-pdf
      January 01, 2008 - second victims" of medical errors.(6) In one study of internal medicine residents, committing an error led

2950. 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.

2951. 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

2952. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73455/psn-pdf
      June 30, 2021 - disease persists over many years.17 In this case, premature closure on the diagnosis of “panic attack” led

2953. A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic | PSNet
      psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-pandemic
      October 30, 2024 - The innovation team, led by experienced hospitalists, attempted to meet the demand for patient care while

2954. Spinal Epidural Abscess | PSNet
      psnet.ahrq.gov/web-mm/spinal-epidural-abscess
      November 13, 2019 - performing root cause analysis using a DEER Taxonomy framework.( 13 ) This activity at our institution led

2955. 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

2956. 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

2957. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
      January 01, 2021 - system-oriented processes that hospital quality improvement professionals had previously implemented, led

2958. Resuscitation Errors: A Shocking Problem | PSNet
      psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
      October 19, 2022 - charged and devices were kept in circulation far in excess of their natural life expectancy of 5–8 years, led

2959. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854897/psn-pdf
      October 31, 2023 - In this case, four significant problems led to the alignment of the “holes” in the “slices” of the Swiss

2960. 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