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Total Results: 4,035 records

Showing results for "occurred".

  1. The Unfinished Patient Safety Agenda | PSNet

    psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda
    August 01, 2005 - The Unfinished Patient Safety Agenda Linda H. Aiken, PhD, RN | August 1, 2005  Also Read a Conversation View more articles from the same authors. Citation Text: Aiken LH. The Unfinished Patient Safety Agenda. PSNet [internet]. Rockville (MD): Agency for Healthc…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33771/psn-pdf
    August 22, 2014 - Beyond the Hospital: the New Frontier of Patient Safety August 22, 2014 Plews-Ogan M. Beyond the Hospital: the New Frontier of Patient Safety. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety Perspective The frontier of patient safety outside the hospital has y…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49519/psn-pdf
    September 01, 2006 - Triple Handoff September 1, 2006 Vidyarthi A. Triple Handoff. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/triple-handoff Case Objectives Appreciate the prevalence of handoffs and sign out related errors. Understand the key elements of a safe and effective written and verbal sign out. List Kotter’s 8 st…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49858/psn-pdf
    April 01, 2019 - What Happened on Telemetry? April 1, 2019 Sandau KE, Funk M. What Happened on Telemetry? PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/what-happened-telemetry Case Objectives Describe current hospital practices for continuous telemetry monitoring. Appreciate key recommendations from the Update to Practice…

  5. Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx Spotlight Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33770/psn-pdf
    August 01, 2014 - In Conversation With… Urmimala Sarkar, MD, MPH August 1, 2014 In Conversation With… Urmimala Sarkar, MD, MPH. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph Editor's note: Urmimala Sarkar, MD, MPH, is associate professor of medicine at the University of California, S…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73300/psn-pdf
    July 01, 2022 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care May 26, 2021 https://psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care Summary The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs,…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73200/psn-pdf
    April 28, 2021 - A Sweet Case of Hidden Hydrogen Ions April 28, 2021 Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions The Case  A?24-year-old, Arabic-speaking?woman?with a history of type 1?diabetes?mellitus, gastroparesis,?and severe e…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33732/psn-pdf
    July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP July 1, 2012 In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp Editor's note: David Blumenthal, MD, MPP, is Chief Health Information and Innovation Officer, Partners Healt…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49834/psn-pdf
    July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety July 1, 2018 Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety Case Objectives Unders…

  11. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? | PSNet

    psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
    March 31, 2021 - Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? Citation Text: Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…

  12. Radiology Missed an Intracranial Bleed in a Lethargic Infant. | PSNet

    psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
    August 21, 2016 - Radiology Missed an Intracranial Bleed in a Lethargic Infant. Citation Text: Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation For…

  13. Peripheral IV in Too Long | PSNet

    psnet.ahrq.gov/web-mm/peripheral-iv-too-long
    September 15, 2011 - SPOTLIGHT CASE Peripheral IV in Too Long Citation Text: Fang C-T. Peripheral IV in Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49810/psn-pdf
    November 01, 2017 - Palliative Care: Comfort vs. Harm November 1, 2017 Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm Case Objectives Recognize errors may be difficult to identify in palliative care. State that medication errors and errors in communica…

  15. Interdisciplinary teamwork | PSNet

    psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
    August 10, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Interdisciplinary teamwork  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet T…

  16. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia | PSNet

    psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
    January 29, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia Citation Text: Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and…

  17. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout | PSNet

    psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
    January 22, 2020 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout Citation Text: Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …

  18. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. | PSNet

    psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
    January 29, 2021 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. Citation Text: Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.. PSNet [internet]. Rockville (MD): Ag…

  19. Project BOOST Increases Patient Understanding of Treatment and Follow-up Care | PSNet

    psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
    February 26, 2025 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 26, 2021 Innovation Contact …

  20. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
    January 01, 2022 - important in the field of oncology, given the 1.9 million new cancer cases and 608,570 cancer deaths that occurred
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