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Total Results: 3,344 records

Showing results for "led".

  1. In Conversation With… Shantanu Agrawal, MD, MPhil | PSNet

    psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil
    February 26, 2025 - of the  Never Events list  was AHRQ commissioning a report called  Making Health Care Safer  that I led

  2. Near Miss with Bedside Medications | PSNet

    psnet.ahrq.gov/web-mm/near-miss-bedside-medications
    February 01, 2006 - At the drug manufacturer's level, a packaging design decision led the atropine and LMWH syringes to look

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852698/psn-pdf
    August 30, 2023 - ectopic pregnancy with possible early delays in care which were flagged in the SureNet system that led

  4. U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument | PSNet

    psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
    February 26, 2025 - Feedback following use of the instrument in several settings led to revisions to the tool.

  5. Mismanagement of Delirium | PSNet

    psnet.ahrq.gov/web-mm/mismanagement-delirium
    February 13, 2014 - continued to experience nighttime agitation and was aggressive toward staff during nights 3–5, which led

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49733/psn-pdf
    May 01, 2015 - Medical advancements over the last 50 years have led to a significant increase in the lifespan of many

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49618/psn-pdf
    February 01, 2011 - case may very well have had the best of intentions, his decision to provide care outside his scope led

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49858/psn-pdf
    April 01, 2019 - The nurse manager for the unit led a root cause analysis to determine what had happened.

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49474/psn-pdf
    March 01, 2005 - extra skin punctures during catheter placement and the delayed catheter changes in obese patients led

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49855/psn-pdf
    March 01, 2019 - Simple checklists used at the time of ordering for self-check might have led the oncologist to identify

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851870/psn-pdf
    July 31, 2023 - /Initiatives/National-Steering-Committee-Patient-Safety/Pages/default.aspx Regina Hoffman: Yes, I led

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74713/psn-pdf
    January 26, 2022 - opioids via patient-controlled analgesia (PCA) and simultaneously via intravenous push has historically led

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49822/psn-pdf
    March 01, 2018 - https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references In this case, several errors led

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865540/psn-pdf
    April 11, 2024 - between medical professionals involves using a standardized tool, such as the I-PASS system, which led

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49615/psn-pdf
    December 01, 2010 - , it became clear the patient had not been moved in her bed since her time in the ED, which likely led

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49651/psn-pdf
    May 01, 2012 - handoffs, but also created a patchwork of coverage systems, including day and night float services that led

  17. In Conversation With…Christine A. Sinsky, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md
    February 26, 2025 - changes were imposed on physicians, but it strikes me that physicians participated in some decisions that led

  18. Peripheral IV in Too Long | PSNet

    psnet.ahrq.gov/web-mm/peripheral-iv-too-long
    September 15, 2011 - The local soft tissue infection led to MRSA bacteremia and then to an epidural abscess.

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49522/psn-pdf
    November 01, 2006 - While this has led to a gradual shift toward the use of process measures (what was done) instead of

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49852/psn-pdf
    February 01, 2019 - of the patient was not adequately communicated to the receiving hospital prior to transfer, which led
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