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Total Results: 4,035 records

Showing results for "occurred".

3321. Departure From Central Line Ritual | PSNet
      psnet.ahrq.gov/web-mm/departure-central-line-ritual
      October 13, 2018 - Departure From Central Line Ritual Citation Text: Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndN…

3322. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49804/psn-pdf
      September 01, 2017 - Transfusion Thresholds in Gastrointestinal Bleeding September 1, 2017 Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding Case Objectives Describe risk factors for poor outcome in patients w…

3323. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33788/psn-pdf
      June 01, 2015 - In Conversation With… Christine Cassel, MD June 1, 2015 In Conversation With… Christine Cassel, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-christine-cassel-md Editor's note: Christine Cassel, MD, is President and CEO of the National Quality Forum (NQF). Dr. Cassel, one of the foun…

3324. Unexpected Drawbacks of Electronic Order Sets | PSNet
      psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
      December 01, 2017 - Unexpected Drawbacks of Electronic Order Sets Citation Text: McGreevey JD. Unexpected Drawbacks of Electronic Order Sets. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX …

3325. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49762/psn-pdf
      June 01, 2016 - The Case of Mistaken Intubation June 1, 2016 Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/case-mistaken-intubation Case Objectives Appreciate that most older adults and many younger chronically ill patients have discussed or documented their preferences for l…

3326. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49780/psn-pdf
      January 01, 2017 - The Missing Abscess: Radiology Reads in the Digital Era January 1, 2017 Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era Case Objectives Identify the most common complication of hysterectomy. Descr…

3327. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33596/psn-pdf
      June 01, 2025 - Failure to Rescue January 29, 2025 Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/failure-rescue Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet primers are regularly reviewed and updated to ensure that they reflect cur…

3328. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49754/psn-pdf
      February 01, 2016 - Picking Up the Cause of the Stroke February 1, 2016 Chopra V. Picking Up the Cause of the Stroke. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/picking-cause-stroke The Case A 62-year-old man with poorly controlled diabetes was transferred to a tertiary care center from a community hospital for management…

3329. Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration | PSNet
      psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
      October 30, 2024 - Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL June 14, 2023 Innov…

3330. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/865864
      January 01, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Diagnostic Error Curated Library Incidence of Diagnostic Errors 25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank. Tehrani ASS, Lee HW, Mathews SC, et al. BMJ Qua…

3331. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules | PSNet
      psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
      March 25, 2020 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules Citation Text: Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…

3332. A Seasonal Care Transition Failure | PSNet
      psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
      June 01, 2016 - A Seasonal Care Transition Failure Citation Text: Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

3333. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
      April 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case April 2006 Is the “Surgical Personality” a Threat to Patient Safety? Source and Credits This presentation is based on the April 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary …

3334. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33572/psn-pdf
      December 15, 2024 - Checklists December 15, 2024 Checklists. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/checklists PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in 2024. Background …

3335. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice | PSNet
      psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
      January 01, 2016 - There is often no agreement on whether an error occurred or not. … Hardeep Singh had a study of diagnostic errors in which 80% of the time when a diagnostic error had occurred

3336. In Conversation With… Mark L. Graber, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
      January 01, 2016 - There is often no agreement on whether an error occurred or not. … Hardeep Singh had a study of diagnostic errors in which 80% of the time when a diagnostic error had occurred

3337. May I Have Another?—Medication Error | PSNet
      psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
      March 01, 2009 - to provide counseling, but it is likely that an insufficient exchange of information and instruction occurred

3338. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852698/psn-pdf
      August 30, 2023 - eight patients may have experienced significant delays in care, and a patient safety event could have occurred

3339. SNFs: Opening the Black Box | PSNet
      psnet.ahrq.gov/web-mm/snfs-opening-black-box
      August 27, 2012 - hypotension, falls, and immobility along with its complications, such as pressure ulcers and, as may have occurred

3340. Standard Deviations | PSNet
      psnet.ahrq.gov/web-mm/standard-deviations
      January 01, 2006 - The most important "error" in this case—a societal rather than a clinical one—occurred before the patient