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Showing results for "limitations".

3321. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
      January 01, 2024 - Spotlight Spotlight A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis 1 Source and Credits This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Garth Utter, MD, MSc, FACS…

3322. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846769/psn-pdf
      March 29, 2023 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. March 29, 2023 Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue The C…

3323. Who Nose Where the Airway Is? | PSNet
      psnet.ahrq.gov/web-mm/who-nose-where-airway
      May 01, 2016 - Who Nose Where the Airway Is? Citation Text: Lee CR. Who Nose Where the Airway Is?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

3324. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49501/psn-pdf
      February 03, 2006 - Lost in Transition February 1, 2006 Beach C. Lost in Transition. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/lost-transition Case Objectives Provide an overview of transitions in continuously operating industries Review cognitive error Describe the complex dynamics of transitions in emergency care Pro…

3325. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49865/psn-pdf
      June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy June 1, 2019 Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy The Case A 75-year-old man with a past medical history of hemorrhagic stroke, coron…

3326. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49567/psn-pdf
      September 01, 2008 - Empiric Steroids: the Good, the Bad, and the Ugly September 1, 2008 Harris ED. Empiric Steroids: the Good, the Bad, and the Ugly. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly Case Objectives Describe appropriate indications for use of steroids. Appreciate contraindicati…

3327. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60857/psn-pdf
      August 26, 2020 - Nothing Called Small Surgery August 26, 2020 Manske C. Nothing Called Small Surgery. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/nothing-called-small-surgery The Case  A 56-year-old female presented to surgical clinic with pain and swelling in left great toe associated with progressive deformity of the …

3328. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33714/psn-pdf
      July 01, 2011 - In Conversation with…William B. Munier, MD, MBA July 1, 2011 In Conversation with…William B. Munier, MD, MBA. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba Editor's note: William B. Munier, MD, MBA, is the Director of the Center for Quality Improvement and Pati…

3329. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49663/psn-pdf
      September 01, 2012 - Peripheral IV in Too Long September 1, 2012 Fang C-T. Peripheral IV in Too Long. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/peripheral-iv-too-long Case Objectives Appreciate the complications associated with peripheral intravenous (IV) catheters. Describe the optimal sterile technique that should be us…

3330. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49816/psn-pdf
      January 01, 2018 - A Painful Medication Reconciliation Mishap January 1, 2018 Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap Case Objectives Recognize that substance use disorders are common in patients with acute pain. Understand th…

3331. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49639/psn-pdf
      November 01, 2011 - Near Miss with Bedside Medications November 1, 2011 Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications Case Objectives Understanding the definition of near miss—also known as close call. Appreciate the importance of close calls in reducin…

3332. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49732/psn-pdf
      May 01, 2015 - Errors in Sepsis Management May 1, 2015 Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/errors-sepsis-management Case Objectives Define sepsis, severe sepsis, and septic shock. Describe the severe sepsis/septic shock resuscitation bundle. Recognize commonly encou…

3333. Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
      January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx Spotlight Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities Source and Credits • This presentation is based on the March 2023 AHRQ WebM&M Spotlight Case o See the full article at https://…

3334. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73456/psn-pdf
      June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia June 30, 2021 Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…

3335. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49678/psn-pdf
      March 01, 2013 - A Weighty Mistake March 1, 2013 Bokser SJ. A Weighty Mistake. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/weighty-mistake Case Objectives Understand factors associated with weight-based dosing medication errors in pediatric populations. Describe how adoption of computerized provider order entry (CPOE) s…

3336. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850675/psn-pdf
      June 14, 2023 - Patient and Family Roles in Safety June 14, 2023 Johnson B, Lee M, Mossburg S. Patient and Family Roles in Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/patient-and-family-roles-safety Moving From Engagement to Partnership Involving patients and families in healthcare decisions about patient c…

3337. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49760/psn-pdf
      May 01, 2016 - Mismanagement of Delirium May 1, 2016 Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/mismanagement-delirium The Case An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although fitted with a cast at a regional ho…

3338. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49573/psn-pdf
      January 01, 2009 - Dangerous Shift November 1, 2008 Patterson ES. Dangerous Shift. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dangerous-shift Case Objectives Review the evidence base on erroneous actions related to shift changes. Understand the limits of standardizing handoffs in preventing errors at shift change. Expla…

3339. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60172/psn-pdf
      March 01, 2021 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart Originally published on June 12, 2020 Last updated on January 11, 2021 https://psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly- reduc…

3340. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities | PSNet
      psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
      November 27, 2019 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities Citation Text: Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…