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Total Results: 3,343 records

Showing results for "led".

3161. In Conversation With… Mark Chassin, MD, MPP, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
      April 26, 2023 - of The Joint Commission's understanding of health care with high reliability organizational learning led

3162. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. | PSNet
      psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
      July 19, 2023 - The suitability of PICC lines for such a broad range of clinical situations has led to highly variable

3163. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. | PSNet
      psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
      March 29, 2023 - Overcrowding in the ED , with boarding of admitted patients, led to inability to room and appropriately

3164. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. | PSNet
      psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
      November 25, 2020 - Although death was averted, it seems quite evident that earlier investigation and intervention might have led

3165. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event | PSNet
      psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
      July 01, 2017 - errors was the wrong blood reaching the patient’s bedside, a high risk near-miss event that may have led

3166. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850361/psn-pdf
      June 14, 2023 - systems-based model for evaluating adverse events, we can see how the holes or gaps in care aligned and led

3167. Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health | PSNet
      psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-health-care-coordination-and-support
      March 27, 2024 - Vermont Blueprint for Health leaders to include the program in its application to CMS, which ultimately led

3168. In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
      March 30, 2020 - I believe this work in part led to me serving the technical expert panel for this report.

3169. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49415/psn-pdf
      September 01, 2003 - unclear A Working Conditions     Staffing levels, skill mix, and workload Nursing shortage has led

3170. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72517/psn-pdf
      November 25, 2020 - Later, problems with data gathering and information processing led to a brief delay in recognizing emerging

3171. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49682/psn-pdf
      April 01, 2013 - Consultation with infectious disease, rheumatology, and neurology led to a provisional diagnosis of

3172. Beeline to Spine | PSNet
      psnet.ahrq.gov/web-mm/beeline-spine
      March 01, 2014 - The impact of a consultant anaesthetist led pre-operative assessment clinic on patients undergoing major

3173. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849661/psn-pdf
      June 28, 2023 - intubation during general anesthesia.28 It is possible that her obesity, and perhaps other social factors, led

3174. In Conversation With… Brian Jarman, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
      March 01, 2015 - HSMRs for years, it was whistleblowers among staff and patients who attracted the public attention that led

3175. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73398/psn-pdf
      June 30, 2021 - This led to the design of a prototype operating room that we then implemented in two ambulatory surgery

3176. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867359/psn-pdf
      December 18, 2024 - In this case, failure to follow unit policy in scanning EBM led to administering EBM from the wrong

3177. Difficult Encounters: A CMO and CNO Respond | PSNet
      psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
      March 01, 2018 - intra-service handoff protocols, to name a few) have not only improved caregiver communication but also led

3178. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853081/psn-pdf
      August 30, 2023 - issues and to catch potential problems, such as labs, medication errors, or procedures that would have led

3179. In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
      August 01, 2016 - The large increase of these types of treatments has led to the emergence of risks not seen previously

3180. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk | PSNet
      psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
      January 31, 2024 - In this case, failure to follow unit policy in scanning EBM led to administering EBM from the wrong mother