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Total Results: 3,344 records

Showing results for "led".

3161. What Happened on Telemetry? | PSNet
      psnet.ahrq.gov/web-mm/what-happened-telemetry
      January 18, 2012 - The nurse manager for the unit led a root cause analysis to determine what had happened.

3162. Getting to the Root of the Matter | PSNet
      psnet.ahrq.gov/web-mm/getting-root-matter
      September 01, 2005 - Getting Started The RCA team is usually led by a member of the institution’s patient safety or quality

3163. A Laceration that Needed a Proper Exam, Not an X-Ray | PSNet
      psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
      November 25, 2020 - failure to perform a complete hand examination and appropriately manage and refer a high-risk laceration led

3164. 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

3165. 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

3166. 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

3167. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73153/psn-pdf
      April 28, 2021 - system-oriented processes that hospital quality improvement professionals had previously implemented, led

3168. 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

3169. Monitoring Fetal Health | PSNet
      psnet.ahrq.gov/web-mm/monitoring-fetal-health
      September 08, 2010 - Although well intended, there are two fundamental differences inherent in centralized monitoring that have led

3170. 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.

3171. 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
      September 27, 2023 - Overcrowding in the ED , with boarding of admitted patients, led to inability to room and appropriately

3172. Spotlight
      psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
      January 01, 2025 - gallbladder, should have prompted a surgical consultation for acute cholecystitis, which might have led

3173. 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

3174. 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

3175. 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

3176. 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

3177. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72516/psn-pdf
      November 25, 2020 - This led to a framing error and premature closure around isolated cardiac pathology.

3178. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60267/psn-pdf
      March 01, 2021 - Vermont Blueprint for Health leaders to include the program in its application to CMS, which ultimately led

3179. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49597/psn-pdf
      February 01, 2010 - sexual history in a confidential setting may have revealed this patient's prior sexual assault and led

3180. 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