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Total Results: 1,802 records

Showing results for "mechanism".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34648/psn-pdf
    April 21, 2015 - Gaps in the continuity of care and progress on patient safety. April 21, 2015 Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ. 2000;320(7237):791-4. https://psnet.ahrq.gov/issue/gaps-continuity-care-and-progress-patient-safety This commentary discusses the concept o…

  2. Are Residency Duty Hour Rules Improving Patient Safety? | PSNet

    psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
    April 01, 2013 - respect to work hours, sleep deprivation, and trying to address fatigue-related errors, the fundamental mechanism

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72739/psn-pdf
    February 10, 2021 - Unfortunately, clinical decompensation was the primary mechanism of error recognition in this case.

  4. Identifying Adverse Events Not Present on Admission: Can We Do It? | PSNet

    psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
    October 01, 2008 - It's not effective to have 6000 hospitals all trying different things with no mechanism to learn from

  5. In Conversation With… Jane Brice, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-jane-brice-md-mph
    May 01, 2019 - accept the patient and so EMS was stuck with a guy who had died in the back of the ambulance and had no mechanism

  6. Safety in the Prehospital Emergency Medical Services Setting | PSNet

    psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
    May 01, 2019 - accept the patient and so EMS was stuck with a guy who had died in the back of the ambulance and had no mechanism

  7. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism | PSNet

    psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
    December 31, 2024 - Unfortunately, clinical decompensation was the primary mechanism of error recognition in this case.

  8. In Conversation With… Christopher P. Landrigan, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-christopher-p-landrigan-md-mph
    April 01, 2013 - respect to work hours, sleep deprivation, and trying to address fatigue-related errors, the fundamental mechanism

  9. Unseen Perils of Urinary Catheters | PSNet

    psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
    January 31, 2024 - Unseen Perils of Urinary Catheters Citation Text: Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar Bib…

  10. In Conversation With… Paul McGann, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
    July 10, 2024 - In Conversation With… Paul McGann, MD March 1, 2016  Citation Text: In Conversation With… Paul McGann, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: …

  11. Difficult Encounters: A CMO and CNO Respond | PSNet

    psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
    March 01, 2018 - SPOTLIGHT CASE Difficult Encounters: A CMO and CNO Respond Citation Text: Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49483/psn-pdf
    June 01, 2005 - Getting to the Root of the Matter June 1, 2005 Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/getting-root-matter Case Objectives Appreciate the goals and limitations of root cause analysis Outline the steps to conduct root cause analysis The Case A…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849661/psn-pdf
    June 28, 2023 - Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery June 28, 2023 Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery. PSNet [internet]. 2023. https://psnet.ahrq.gov/web…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838221/psn-pdf
    September 28, 2022 - In Conversation With... Freya Spielberg, MD, MPH September 28, 2022 In Conversation With.. Freya Spielberg, MD, MPH. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph Editor’s Note: Freya Spielberg, MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social enterp…

  15. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
    January 01, 2024 - Spotlight Spotlight Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Christian Bohringer, MBBS, …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865429/psn-pdf
    April 24, 2024 - Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery April 24, 2024 Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery…

  17. Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx Spotlight A Missed Bowel Perforation – the Importance of Diagnostic Reasoning Source and Credits • This presentation is based on the September 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/web…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49564/psn-pdf
    July 01, 2008 - Dependence vs. Pain July 1, 2008 Gordon AJ. Dependence vs. Pain . PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dependence-vs-pain Case Objectives Define opioid dependence and opioid withdrawal syndrome. Describe the treatment of opioid withdrawal syndrome including the use of the Clinical Opioid Withdra…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73102/psn-pdf
    July 01, 2022 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use March 31, 2021 https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail- community-dwelling Summary Care management staff (such …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33859/psn-pdf
    June 01, 2018 - In Conversation With… Richard Hoppmann, MD June 1, 2018 In Conversation With… Richard Hoppmann, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-richard-hoppmann-md Editor's note: Dr. Hoppmann is the Dorothea H. Krebs Endowed Chair of Ultrasound Education, Professor of Medicine, and Dire…
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