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Showing results for "limitations".

3741. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-454
      September 25, 2024 - September 4, 2024 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, repor…

3742. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49423/psn-pdf
      November 01, 2003 - The Missing Suction Tip November 1, 2003 Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missing-suction-tip Case Objectives Identify the risk factors for retained foreign bodies. Understand methods used to prevent and identify retained foreign bodies. Apprecia…

3743. Delayed Clozapine Prescription in an Elderly Man With Dementia | PSNet
      psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
      August 06, 2014 - Delayed Clozapine Prescription in an Elderly Man With Dementia Citation Text: Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cita…

3744. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
      January 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case January 2008 How Do Providers Recover from Errors? Source and Credits This presentation is based on the January 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Colin P. West, MD, PhD, Mayo Clini…

3745. Feeling No Pain | PSNet
      psnet.ahrq.gov/web-mm/feeling-no-pain
      August 30, 2023 - Feeling No Pain Citation Text: Bogner MS. Feeling No Pain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

3746. Patient Safety in the Physician Office Setting | PSNet
      psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
      November 04, 2015 - Patient Safety in the Physician Office Setting Nancy C. Elder, MD, MSPH | May 1, 2006  View more articles from the same authors. Citation Text: Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…

3747. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33762/psn-pdf
      March 01, 2014 - In Conversation With… Alison Holmes, MD, MPH March 1, 2014 In Conversation With… Alison Holmes, MD, MPH. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph Editor's note: Dr. Alison Holmes is Director of Infection Prevention and Control at Imperial College Healthcare NHS …

3748. Missing ECG and Missed Diagnosis Lead to Dangerous Delay | PSNet
      psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
      March 01, 2015 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay Citation Text: O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: G…

3749. Procedural Mishap: Learning Curve? | PSNet
      psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
      April 28, 2021 - Procedural Mishap: Learning Curve? Citation Text: Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

3750. Febrile Neutropenia and an Almost Fatal Medication Error | PSNet
      psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
      February 01, 2012 - Febrile Neutropenia and an Almost Fatal Medication Error Citation Text: Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: …

3751. The Dangerous Detour | PSNet
      psnet.ahrq.gov/web-mm/dangerous-detour
      November 28, 2018 - The Dangerous Detour Citation Text: Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…

3752. An Untimely End Despite End-of-Life Care Planning | PSNet
      psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
      February 01, 2012 - An Untimely End Despite End-of-Life Care Planning Citation Text: Elia G, Barbour S, Anderson WG. An Untimely End Despite End-of-Life Care Planning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: …

3753. Miscommunication in the OR Leads to Anticoagulation Mishap | PSNet
      psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
      May 08, 2019 - Miscommunication in the OR Leads to Anticoagulation Mishap Citation Text: Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Forma…

3754. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848125/psn-pdf
      April 26, 2023 - Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units April 26, 2023 McGrath S, Blike G, Gale B, et al. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-…

3755. "Superficial" Report Leads to "Deep" Problem | PSNet
      psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
      July 01, 2012 - "Superficial" Report Leads to "Deep" Problem Citation Text: Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndN…

3756. Sloppy and Paste | PSNet
      psnet.ahrq.gov/web-mm/sloppy-and-paste
      February 02, 2011 - Sloppy and Paste Citation Text: Hirschtick RE. Sloppy and Paste. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

3757. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73335/psn-pdf
      May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition Error May 26, 2021 Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error The Case A 4-year-old (former 33-week premature) boy with a …

3758. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49837/psn-pdf
      August 01, 2018 - Abdominal Aortic Aneurysm Screening August 1, 2018 Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening Case Objectives Describe risk factors associated with abdominal aortic aneurysm. Identify patient populations meeting criteria fo…

3759. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49815/psn-pdf
      December 01, 2017 - Over-the-Counter Oversight December 1, 2017 Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/over-counter-oversight The Case A 56-year-old man was evaluated in the burn clinic for a second-degree burn on his chest. Although portions of his skin we…

3760. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-12/spotlight_case_strongyloides_final_11.21.22.pdf
      January 01, 2022 - Spotlight Spotlight Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis Source and Credits • This presentation is based on the November 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Narath Carlile MD MPH,…