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Total Results: 6,293 records

Showing results for "led".

4801. 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

4802. In Conversation With… J. Bryan Sexton, PhD, MA | PSNet
      psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
      February 26, 2025 - Ten years from now, people will probably still say that the projects that led to checklists being the

4803. Behavioral Counseling to Prevent Sexually Transmitted Infections: Recommendation Statement (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/8U8tcAjprBFpANg2GVAJVp
      March 01, 2009 - 20-minute individual counseling sessions (a less intensive intervention than the others re- viewed) led

4804. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. | PSNet
      psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
      November 30, 2021 - Later, problems with data gathering and information processing led to a brief delay in recognizing emerging

4805. “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

4806. 124-Cusp-Science-Safety-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docx
      April 01, 2025 - Look at the Swiss Cheese model to prompt of all the contributing factors or holes in the system that led

4807. The Role of the FDA in Ensuring Device Safety | PSNet
      psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
      May 28, 2020 - tools, as well as the challenge of getting clinical studies after a product is out in the marketplace, led

4808. 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

4809. 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

4810. 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

4811. Meeting Minutes, March 2021 | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/events/nac/2021-03-nac/nacmtg031821-minutes.html
      July 01, 2021 - Edgman-Levitan added that Kedar Mate at IHI has led much of the work, including efforts to improve equity

4812. 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

4813. 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

4814. Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-November_45.pdf
      January 01, 2007 - A senior resident physician led morning work rounds.

4815. Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-David_13.pdf
      March 19, 2008 - You’ve led the horse to water, now how do you get him to drink: Managing change and increasing utilization

4816. 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

4817. Using Barcode Medication Administration to Improve Quality and Safety (pdf file)
      digital.ahrq.gov/sites/default/files/docs/lesson/09-0023-ef-bcma.pdf
      December 01, 2008 - Similarly, grantees found that the introduction of BCMA and eMAR technologies led to substantial changes

4818. Layout 1 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/juvenile-arthritis-dmards_executive.pdf
      September 01, 2011 - Changes in the definition of JIA (e.g., JRA, JCA) may have led to the inclusion in studies of individuals

4819. Facilitating the Implementation of EPC Reports_Methods Research Report (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-report-facilitating-implementation-pilot.pdf
      October 01, 2019 - A draft of this product was presented to stakeholders for feedback which led to modifications and enhancement

4820. 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.