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Total Results: 4,035 records

Showing results for "occurred".

  1. Antiseizure Medication Disorder | PSNet

    psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
    April 01, 2006 - binding variability has on phenytoin serum level interpretation is necessary to understand the error that occurred

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49790/psn-pdf
    April 01, 2017 - Patient Allergies and Electronic Health Records April 1, 2017 Doyle MJ. Patient Allergies and Electronic Health Records. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records The Case A 40-year-old woman presented with recurring intense right upper quadrant pain, whi…

  3. Medication Reconciliation | PSNet

    psnet.ahrq.gov/primer/medication-reconciliation
    March 15, 2025 - Medication Reconciliation Citation Text: Medication Reconciliation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…

  4. Culture of Safety | PSNet

    psnet.ahrq.gov/primer/culture-safety
    September 15, 2024 - Culture of Safety Citation Text: Culture of Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Dow…

  5. In Conversation With… Mary Dixon-Woods, DPhil | PSNet

    psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
    March 01, 2017 - In Conversation With… Mary Dixon-Woods, DPhil March 1, 2017  Also Read an Essay Citation Text: In Conversation With… Mary Dixon-Woods, DPhil. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

  6. Building a Safety Program in a Vast Health Care Network | PSNet

    psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
    March 01, 2019 - Building a Safety Program in a Vast Health Care Network Paul E. Phrampus, MD | March 1, 2019  Also Read a Conversation View more articles from the same authors. Citation Text: Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet].…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841306/psn-pdf
    December 14, 2022 - Resilient Healthcare and the Safety-I and Safety-II Frameworks December 14, 2022 Deutsch ES, Van CM, Mossburg SE. Resilient Healthcare and the Safety-I and Safety-II Frameworks. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks Resilient healthca…

  8. 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…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49464/psn-pdf
    December 27, 2020 - Lap Burn October 1, 2004 Ball K. Lap Burn. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lap-burn The Case A woman was scheduled for an elective diagnostic laparoscopy for dysfunctional uterine bleeding. After accessing the abdomen with the trocar without complication, the surgeon inserted the laparoscope…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33817/psn-pdf
    October 01, 2016 - Health Care Data Science for Quality Improvement and Patient Safety October 1, 2016 Rajkomar A. Health Care Data Science for Quality Improvement and Patient Safety. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety Perspective Background Ha…

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

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.209_slideshow.ppt
    December 01, 2009 - Spotlight Case [MONTH] 2003 Spotlight Case Standard Deviations Source and Credits This presentation is based on the December 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: James E. Sabin, MD Harvard Medical School; Harvard Pilgrim Heal…

  12. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.248_slideshow.ppt
    September 01, 2011 - Spotlight Case July 2008 Spotlight Case The Safety and Quality of Long Term Care * * Source and Credits This presentation is based on the September 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Amy A. Vogelsmeier, PhD, RN, GCNS-BC, Uni…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33777/psn-pdf
    January 01, 2015 - Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care January 1, 2015 Plsek PE. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33586/psn-pdf
    December 15, 2024 - Alert Fatigue December 15, 2024 Alert Fatigue. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/alert-fatigue 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. Bac…

  15. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.434_slideshow.ppt
    February 01, 2018 - PowerPoint Presentation Spotlight Signout Fallout 1 Source and Credits This presentation is based on the February 2018 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH, Harvard M…

  16. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
    October 28, 2020 - bundled care, there is scant published literature on the dangers of erroneous diagnoses of sepsis (as occurred

  17. Privacy or Safety? | PSNet

    psnet.ahrq.gov/web-mm/privacy-or-safety
    December 01, 2011 - In this hospital, signout occurred with a paper-based system.

  18. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-05/final_cme_reviewed_-_spotlight_missing_a_large_vessel_occlusion_stroke_04.14.2022_-_copy.pdf
    January 01, 2022 - • A stroke alert was not activated upon ED arrival, nor at the first suspicion that a stroke had occurred

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857258/psn-pdf
    November 30, 2023 - Hypoxemia presumably occurred because the persistent neuromuscular block induced atelectasis at the

  20. In Conversation With… Rebecca Lawton, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
    March 24, 2025 - We could argue that if certain system-level problems occurred across 100, 200 events, then it might be
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