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Total Results: 4,038 records

Showing results for "occurred".

3261. 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 …

3262. 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…

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. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
      August 01, 2014 - PowerPoint Presentation Spotlight Pitfalls in Diagnosing Necrotizing Fasciitis This presentation is based on the July/August 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Terence Goh, MBBS, Department of Plastic Surgery, Singapore General Hos…

3265. Team Training: Classroom Training vs. High-Fidelity Simulation | PSNet
      psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
      January 12, 2011 - Team Training: Classroom Training vs. High-Fidelity Simulation Stephen D. Pratt, MD and Benjamin P. Sachs, MB | March 1, 2006  View more articles from the same authors. Citation Text: Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulatio…

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. 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…

3268. 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 …

3269. 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…

3270. 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 (…

3271. Written Signout: It Only Works If You Use The Right One | PSNet
      psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one
      April 24, 2018 - Written Signout: It Only Works If You Use The Right One Citation Text: Lewis K, Rosenbluth G. Written Signout: It Only Works If You Use The Right One. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: …

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. 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

3274. 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.

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. 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

3277. 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

3278. 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

3279. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49593/psn-pdf
      October 01, 2009 - nasal cavity (so that its external portion was no longer extruding from the nose), but presumably this occurred … trachea and right bronchus.(1) One death was reported in a case with an aspirated airway, although this occurred … Nonetheless, some discussion regarding the NPA should have occurred prior to intubation, since the anesthesiologist

3280. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49863/psn-pdf
      May 01, 2019 - multiple units of blood, and fortunately the injury was repaired before more serious consequences occurred … to ensure safety issues are recognized, announced, and treated by the team in a timely fashion, as occurred … In this case, the first challenge occurred when the anesthesiologist alerted the surgeon during the