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Total Results: 4,038 records

Showing results for "occurred".

3821. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33822/psn-pdf
      January 01, 2017 - In Conversation With… Paul H. O'Neill, MPA January 1, 2017 In Conversation With… Paul H. O'Neill, MPA. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa Editor's note: Mr. O'Neill served as the United States Secretary of the Treasury under President George W. Bush and, prio…

3822. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49498/psn-pdf
      January 01, 2006 - An Ounce of Prevention January 1, 2006 Kucher N. An Ounce of Prevention. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/ounce-prevention Case Objectives Assess risk for venous thromboembolism (VTE) in hospitalized patients List recommended strategies for VTE prevention for various risk groups Identify pat…

3823. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.113_slideshow.ppt
      January 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case January 2006 An Ounce of Prevention Source and Credits This presentation is based on the Jan. 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Nils Kucher, MD; University Ho…

3824. An Ounce of Prevention | PSNet
      psnet.ahrq.gov/web-mm/ounce-prevention
      February 17, 2011 - SPOTLIGHT CASE An Ounce of Prevention Citation Text: Kucher N. An Ounce of Prevention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…

3825. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49408/psn-pdf
      July 01, 2003 - Check the Wristband July 1, 2003 Rosenthal M. Check the Wristband. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/check-wristband The Case The patient was a 28-year-old female awaiting ambulatory surgery. She was very anxious about the impending surgery. The patient spoke English and appeared to be of aver…

3826. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33654/psn-pdf
      August 01, 2007 - In Conversation with...James L. Reinertsen, MD August 1, 2007 In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md Editor's Note: James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting firm …

3827. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49573/psn-pdf
      January 01, 2009 - Dangerous Shift November 1, 2008 Patterson ES. Dangerous Shift. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dangerous-shift Case Objectives Review the evidence base on erroneous actions related to shift changes. Understand the limits of standardizing handoffs in preventing errors at shift change. Expla…

3828. Premature Extubation | PSNet
      psnet.ahrq.gov/web-mm/premature-extubation
      May 25, 2011 - Premature Extubation Citation Text: Sagana R, Hyzy RC. Premature Extubation. 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 P…

3829. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33774/psn-pdf
      December 01, 2014 - In Conversation With… Edward Kelley, PhD December 1, 2014 In Conversation With… Edward Kelley, PhD. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-edward-kelley-phd Editor's note: Edward Kelley, PhD, is Director of Service Delivery and Safety for the World Health Organization (WHO). He ha…

3830. The Hazards of Distraction: Ticking All the EHR Boxes | PSNet
      psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
      April 09, 2014 - SPOTLIGHT CASE The Hazards of Distraction: Ticking All the EHR Boxes Citation Text: Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation …

3831. The Forgotten Line | PSNet
      psnet.ahrq.gov/web-mm/forgotten-line
      March 11, 2011 - The Forgotten Line Citation Text: Render ML. The Forgotten Line. 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 EndNote 7 XML Endnote tagged PubMedId RIS …

3832. Spotlight (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
      January 01, 2019 - Spotlight Spotlight Mistaken Attribution, Diagnostic Misstep * Source and Credits This presentation is based on the January 2019 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD …

3833. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
      September 01, 2014 - PowerPoint Presentation Spotlight A Lot of Pain (Medications) 1 This presentation is based on the September 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Shoshana J. Herzig, MD, MPH, Division of General Medicine, Beth Israel Deaconess Medic…

3834. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33744/psn-pdf
      February 01, 2013 - In Conversation With… Beverley H. Johnson February 1, 2013 In Conversation With… Beverley H. Johnson. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson Editor's note: Beverley H. Johnson is the President and Chief Executive Officer of the Institute for Patient- and Family-…

3835. Innovations | PSNet
      psnet.ahrq.gov/innovations
      February 26, 2025 - Innovations The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …

3836. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842923/psn-pdf
      February 01, 2023 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. February 1, 2023 Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. PSNet [internet]. …

3837. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-469
      December 31, 2024 - January 8, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports…

3838. Diagnostic Error | PSNet
      psnet.ahrq.gov/curated-library/diagnostic-error
      July 20, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Diagnostic Error  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Karen Cosby, AHRQ Date Created: May 8, …

3839. Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care | PSNet
      psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
      July 23, 2024 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL December 23, 2020 …

3840. Long-term Care and Patient Safety | PSNet
      psnet.ahrq.gov/primer/long-term-care-and-patient-safety
      February 24, 2022 - Long-term Care and Patient Safety Citation Text: Bakerjian D. Long-term Care and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …