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Showing results for "mechanisms".

  1. Near Miss with Bedside Medications | PSNet

    psnet.ahrq.gov/web-mm/near-miss-bedside-medications
    February 01, 2006 - Frequency of near misses relative to medical errors Because of the lack of systematic mechanisms to

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74713/psn-pdf
    January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking January 26, 2022 Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking Disclosure of Relevant Financial Relationships: As a provider ac…

  3. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
    January 01, 2022 - Spotlight Spotlight Patient Safety Events Involving Opioid Dose Stacking Source and Credits • This presentation is based on the January 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: Hollie Porras, PharmD, BCPS and Cathy Lammers…

  4. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest | PSNet

    psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
    February 01, 2023 - SPOTLIGHT CASE When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Citation Text: Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49579/psn-pdf
    March 21, 2009 - All in the History March 21, 2009 Fee C. All in the History. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/all-history Case Objectives Describe the Emergency Medical Treatment and Active Labor Act (EMTALA) and understand that it does not apply to transfers to emergency departments from non-acute care faci…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837660/psn-pdf
    July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse Outcomes July 8, 2022 Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes The Cases Case 1: A 64-year-old man came in for a routine bron…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49758/psn-pdf
    April 01, 2016 - Dropping to New Lows April 1, 2016 Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/dropping-new-lows Case Objectives State how to manage diabetes medications when patients are admitted to the hospital Describe a guideline-recommended insulin regimen for a hospitaliz…

  8. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. | PSNet

    psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
    November 25, 2020 - Early Warning Systems Multiple institutions and organizations have developed protocols and mechanisms

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867676/psn-pdf
    February 26, 2025 - Responding to Patient Safety Events February 26, 2025 Shaikh U. Responding to Patient Safety Events. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/responding-patient-safety-events Background Patient safety events that occur in health care facilities require prompt action to ensure that further harm is mit…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33571/psn-pdf
    March 15, 2025 - Reporting Patient Safety Events March 15, 2025 Reporting Patient Safety Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/reporting-patient-safety-events PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in th…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49800/psn-pdf
    July 01, 2017 - The Hidden Harms of Hand Sanitizer July 1, 2017 Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer The Case A 57-year-old woman with a history of alcohol abuse and severe depression was admitted to the hospital for community-acquired pn…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33612/psn-pdf
    May 01, 2005 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience May 1, 2005 Conway JB, Weingart SN. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/organizat…

  13. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.233_slideshow.ppt
    February 01, 2011 - Spotlight Case July 2008 Spotlight Case One Toxic Drug Is Not Like Another * * Source and Credits This presentation is based on the February 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Eric S. Holmboe, MD, American Board of Internal…

  14. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.221_slideshow.ppt
    July 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Weighing in on Surgical Safety * * Source and Credits This presentation is based on the July 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jay B. Brodsky, MD, Stanford University Medical Cente…

  15. Suicidal Ideation in the Family Medicine Clinic | PSNet

    psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
    October 01, 2007 - Warning signs (thoughts, behaviors, situations) Internal coping mechanisms People/social settings that

  16. Transitions in Adolescent Medicine | PSNet

    psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
    August 04, 2021 - youth that can assist in the transition-of-care quality improvement process.( 9 ) Clinics have employed mechanisms

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49771/psn-pdf
    July 01, 2016 - enable easy back-tracking from erroneous choices.(14) Given how common picklist errors are, there are mechanisms

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49843/psn-pdf
    October 01, 2018 - Comparison of QSOFA score and SIRS criteria as screening mechanisms for emergency department sepsis.

  19. Dropping to New Lows | PSNet

    psnet.ahrq.gov/web-mm/dropping-new-lows
    December 18, 2024 - SPOTLIGHT CASE Dropping to New Lows Citation Text: Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33855/psn-pdf
    April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM April 1, 2018 In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm Editor's note: Dr. Krumholz, Harold H. Hines, Jr. Professor of Medicine at the Yale School of Medicine and Directo…
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