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Showing results for "occurred".

3521. Promising Areas for Patient Safety Research | PSNet
      psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
      November 02, 2016 - Promising Areas for Patient Safety Research P. Jeffrey Brady, MD, MPH; William B. Munier, MD, MBA; Irim Azam, MPH | December 1, 2003  View more articles from the same authors. Citation Text: Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. …

3522. Pitfalls in Diagnosing Necrotizing Fasciitis | PSNet
      psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
      March 24, 2021 - SPOTLIGHT CASE Pitfalls in Diagnosing Necrotizing Fasciitis Citation Text: Goh T, Goh LG. Pitfalls in Diagnosing Necrotizing Fasciitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: …

3523. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865466/psn-pdf
      March 27, 2024 - Equity in Patient Safety March 27, 2024 Thomas A, Lee M, Mossburg S. Equity in Patient Safety. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/equity-patient-safety Introduction Safety and equity are among the central components that determine quality of care, according to nonprofit advisory agencies l…

3524. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations | PSNet
      psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
      October 27, 2022 - SPOTLIGHT CASE Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations Citation Text: Tan F, Johl K, Kotova M. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations. PSNet [internet]. Rockville (MD): Agency for He…

3525. Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet
      psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
      September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement Carole Stockmeier, MHA, BS, Eric Thomas, MD, MPH, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD | September 24, 2024  Also Read the Conversations In Conversation with Ca…

3526. How Does Health Care Simulation Affect Patient Care? | PSNet
      psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
      August 01, 2018 - How Does Health Care Simulation Affect Patient Care? Joseph O. Lopreiato, MD, MPH | August 1, 2018  Also Read a Conversation View more articles from the same authors. Citation Text: Lopreiato JO. How Does Health Care Simulation Affect Patient Care?. PSNet [inter…

3527. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60722/psn-pdf
      February 06, 2023 - Coronavirus Disease 2019 (COVID-19) and Diagnostic Error January 11, 2022 Desai AN, Romano PS. Coronavirus Disease 2019 (COVID-19) and Diagnostic Error. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error Originally published July 30, 2020. Updated January …

3528. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49619/psn-pdf
      February 01, 2011 - Paradoxical Pulse February 1, 2011 Roy CL. Paradoxical Pulse. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/paradoxical-pulse The Case An 80-year-old man with paroxysmal atrial fibrillation and symptomatic bradycardia underwent successful pacemaker placement as an outpatient. The patient was restarted on …

3529. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
      February 01, 2012 - Spotlight Case July 2008 Spotlight Case E-prescribing: E for Error? 1 2 Source and Credits This presentation is based on the February 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Elisa W. Ashton, PharmD, Assistant Clinical Professor, Departm…

3530. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33868/psn-pdf
      October 01, 2018 - Safety in the Retail Pharmacy October 1, 2018 Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/safety-retail-pharmacy Perspective There are approximately 67,000 retail/community pharmacies dispensing 4.4 billion prescriptions each year.(1) Many patients interact w…

3531. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33644/psn-pdf
      December 01, 2006 - Establishing a Safety Culture: Thinking Small December 1, 2006 Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small Perspective Safety cultures are the holy grail in any risky industry. Like all holy grails, th…

3532. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33679/psn-pdf
      January 01, 2009 - Disclosure of Medical Error January 1, 2009 Kachalia A. Disclosure of Medical Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/disclosure-medical-error Perspective Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts advocate that greater discl…

3533. Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
      January 01, 2020 - Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx Spotlight When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Source and Credits • This presentation is based on the September 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psne…

3534. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33829/psn-pdf
      March 01, 2017 - Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety March 1, 2017 Singer SJ. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change…

3535. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49577/psn-pdf
      January 01, 2009 - Are Two Insulin Pumps Better Than One? January 1, 2009 Cook CB. Are Two Insulin Pumps Better Than One? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one The Case A 62-year-old man with type 1 diabetes mellitus was admitted to the hospital for coronary artery bypass graft surge…

3536. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49867/psn-pdf
      July 02, 2019 - Diuretics and Electrolyte Abnormalities July 2, 2019 Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities Case Objectives Recognize that thiazide diuretics can lead to serious adverse events. State how commonly used t…

3537. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49656/psn-pdf
      June 01, 2012 - Comanagement: Who's in Charge? June 1, 2012 Cheng HQ. Comanagement: Who's in Charge? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/comanagement-whos-charge The Case A 77-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with a left hip fracture to the orthopedic surg…

3538. Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary | PSNet
      psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
      February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL February 26, 2025 Innovation Contact …

3539. Healthcare-associated Infections | PSNet
      psnet.ahrq.gov/primer/health-care-associated-infections
      December 15, 2024 - Healthcare-associated Infections Citation Text: Healthcare - Associated Infections. 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 t…

3540. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867845/psn-pdf
      February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary February 26, 2025 https://psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation- summary Summary This innovation describes the Veteran Health Administration (VHA) National Center for Patient Saf…