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Total Results: 3,178 records

Showing results for "led".

3061. In Conversation with…Janet Corrigan, PhD, MBA | PSNet
      psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
      April 01, 2010 - This has led to great variability in the approaches that local stakeholders employ to report quality

3062. In Conversation With… Lawrence Smith, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
      February 01, 2012 - The death of 18-year-old Libby Zion at The New York Hospital in 1984 led to the recommendation by the

3063. Missed Nursing Care: A Key Measure for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
      March 01, 2018 - In England, high mortality rates led to the detection of serious care failings at the Mid Staffordshire

3064. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case | PSNet
      psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
      October 02, 2013 - Consultation with infectious disease, rheumatology, and neurology led to a provisional diagnosis of primary

3065. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? | PSNet
      psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
      March 01, 2015 - HSMRs for years, it was whistleblowers among staff and patients who attracted the public attention that led

3066. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853774/psn-pdf
      September 27, 2023 - Doing so could have expedited her transfer from the waiting room to a treatment bed and may have led

3067. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74830/psn-pdf
      June 01, 2022 - group of vascular access experts from around the world, including several HMS member hospitals, and led

3068. A Postpartum Woman with an Erroneous SARS-CoV-2 Test | PSNet
      psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
      December 23, 2020 - population with low prevalence of SARS-CoV-2 (e.g., ≤2%). 13 , 14 , 15   False positive antigen results led

3069. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837913/psn-pdf
      August 31, 2022 - Miscommunication amongst team members led to a delay in the administration of high-flow oxygen.

3070. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations | PSNet
      psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
      September 27, 2023 - gallbladder, should have prompted a surgical consultation for acute cholecystitis, which might have led

3071. Miscommunication During the Interhospital Transport of a Critically Ill Child | PSNet
      psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
      March 27, 2024 - Miscommunication amongst team members led to a delay in the administration of high-flow oxygen.

3072. Premature Closure: Was It Just Syncope? | PSNet
      psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
      February 10, 2021 - This led to a framing error and premature closure around isolated cardiac pathology.

3073. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? | PSNet
      psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
      September 01, 2006 - Everybody learned from a particular person or an institution—which led to, you know, this is the Penn

3074. Balancing Supervision and Autonomy: An Ongoing Tension | PSNet
      psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension
      February 01, 2012 - The death of 18-year-old Libby Zion at The New York Hospital in 1984 led to the recommendation by the

3075. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841467/psn-pdf
      December 14, 2022 - A goals-of-care discussion was led by the palliative care service; the patient and his designated decision-makers

3076. Becoming a Certified Professional in Patient Safety—A Pharmacist's Perspective | PSNet
      psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-pharmacists-perspective
      June 01, 2016 - safety officer, it is vital that I listen to the health care team when they explain the events that led

3077. Making Just Culture a Reality: One Organization's Approach | PSNet
      psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
      October 01, 2007 - November 1, 2016 Sustained impact of a pediatric resident-led patient safety council.

3078. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836976/psn-pdf
      April 27, 2022 - Her wounds led to significant blood loss.

3079. In Conversation with…Donald M. Berwick, MD, MPP | PSNet
      psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
      November 01, 2005 - In December 2004, he announced an IHI-led "Campaign to Save 100,000 Lives"—promoting the implementation

3080. Safety and Medical Education | PSNet
      psnet.ahrq.gov/perspective/safety-and-medical-education
      December 01, 2013 - commentary by two noted patient safety experts raised concern that further restriction of duty hours has led