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Total Results: 4,035 records

Showing results for "occurred".

3261. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49775/psn-pdf
      November 01, 2016 - Unexpected Drawbacks of Electronic Order Sets November 1, 2016 McGreevey JD. Unexpected Drawbacks of Electronic Order Sets. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets The Case A 70-year-old man with stage 4 prostate cancer presented to the emergency department …

3262. Amphotericin Toxicity | PSNet
      psnet.ahrq.gov/web-mm/amphotericin-toxicity
      April 01, 2014 - Amphotericin Toxicity Citation Text: Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…

3263. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49458/psn-pdf
      September 01, 2004 - Poor Prognosis September 1, 2004 Lamont EB. Poor Prognosis. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/poor-prognosis Case Objectives Understand the current limitations of physicians' ability to provide prognoses. List the variables that can be used to guide treatment decisions and prognostication in e…

3264. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33670/psn-pdf
      July 01, 2008 - In Conversation with...Albert Wu, MD, MPH July 1, 2008 In Conversation with..Albert Wu, MD, MPH. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph Editor's note: Albert Wu, MD, MPH, is Professor of Health Policy and Management at the Johns Hopkins School of Public Health…

3265. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49605/psn-pdf
      June 01, 2010 - Acute Respiratory Arrest in Pregnancy June 1, 2010 Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy The Case A 35-year-old woman was 38 weeks pregnant with twins (G3P2). When she developed acute onset of shortness of breath an…

3266. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50696/psn-pdf
      November 27, 2019 - Complications of Vascular Access Procedures in Patients with Kidney Disease November 27, 2019 Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease The Ca…

3267. Mistaken Identity | PSNet
      psnet.ahrq.gov/web-mm/mistaken-identity
      December 18, 2014 - Mistaken Identity Citation Text: Hall LW. Mistaken Identity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

3268. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49809/psn-pdf
      October 01, 2017 - Hyperbilirubinemia Refractory to Phototherapy October 1, 2017 Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy The Case A 1-day-old full-term infant was noted to have elevated total serum bilirubin (…

3269. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49433/psn-pdf
      June 23, 2021 - Environmental Safety in the OR February 1, 2004 Linkin DR, Lautenbach E. Environmental Safety in the OR . PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/environmental-safety-or The Case The infection control department of a hospital noticed a marked increase in the rates of post-operative sternal wound inf…

3270. Do Me a Favor | PSNet
      psnet.ahrq.gov/web-mm/do-me-favor
      September 12, 2016 - Do Me a Favor Citation Text: Williamson A. Do Me a Favor. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

3271. Wrong-Time Error With High-Alert Medication | PSNet
      psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
      February 01, 2014 - Wrong-Time Error With High-Alert Medication Citation Text: Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX…

3272. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850678/psn-pdf
      June 14, 2023 - Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration June 14, 2023 https://psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults- risk-hospital Summary To address a well-documented hospital adverse outco…

3273. Medication Safety Events Related to Diagnostic Imaging | PSNet
      psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
      January 26, 2022 - Medication Safety Events Related to Diagnostic Imaging Citation Text: Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Fo…

3274. Patient Safety 2030. | PSNet
      psnet.ahrq.gov/issue/patient-safety-2030
      April 13, 2016 - February 26, 2014 External Inquiry into the adverse incident that occurred at Queen's

3275. A model of chemotherapy education for novice oncology nurses that supports a culture of safety. | PSNet
      psnet.ahrq.gov/issue/model-chemotherapy-education-novice-oncology-nurses-supports-culture-safety
      September 24, 2010 - November 30, 2016 External Inquiry into the adverse incident that occurred at Queen's

3276. Which Line: Ordering Provider or Proceduralist? | PSNet
      psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
      September 16, 2015 - inspection, the least effective approach, adverse events are captured after the error or issue has occurred … For this case, self-check would have occurred if the ordering physician had confirmed the order was for … Control means a system that captures when an error has occurred and blocks propagation, preventing patient … This type of successive check might well have identified the error before the adverse event occurred.

3277. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49681/psn-pdf
      April 01, 2013 - As occurred in this case, multiple failures across the PN-use process are usually identified in retrospect … Multiple warnings occurred daily with this patient's PN order, and ignoring them contributed to the error … One PN-related fatality occurred when an infant received a 1000-fold excess of zinc because of a mix-up … per day in another pediatric case was identified during PN infusion but before any adverse effect occurred

3278. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49419/psn-pdf
      October 01, 2003 - In the present case, as far as one can tell, no problems occurred in the routine biopsy, labeling, and … The wrong site surgery occurred because the surgeon remembered, incorrectly, that he had biopsied the … Patients who have not experienced errors report that, if a harmful error occurred in their treatment

3279. A Potent Medication Administered in a Not So Viable Route | PSNet
      psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
      July 20, 2016 - Of these, the majority occurred when vasopressors were given for a very long duration (55.9 ± 68.1 hours … The 2-hour limit was chosen because very few published cases of local tissue injury events occurred within … frame—of 138 published cases of local tissue injury where the duration of infusion was given, only 4 occurred

3280. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49451/psn-pdf
      June 01, 2004 - This particular event occurred on a Friday, as the physician left for the weekend. … follow-up on an important radiographic or laboratory test result) may reduce the risk of lapses such as occurred … That appears to have occurred here since laboratory staff called infection control staff, who called