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Showing results for "occurred".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867652/psn-pdf
    February 26, 2025 - The Evolution of Root Cause Analysis February 26, 2025 Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis Introduction Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…

  2. Health Information Exchange Policy Issues | Digital Healthcare Research

    digital.ahrq.gov/health-information-exchange-policy-issues
    January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…

  3. DNR in the OR and Afterwards | PSNet

    psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
    July 01, 2003 - DNR in the OR and Afterwards Citation Text: Lo B. DNR in the OR and Afterwards. 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 XML Endnote tagge…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865418/psn-pdf
    March 27, 2024 - Cybersecurity and How to Maintain Patient Safety March 27, 2024 Pelletreau B, Riggi J, Gale B, et al. Cybersecurity and How to Maintain Patient Safety. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety Introduction The integration of information technology (I…

  5. Hold the tPA | PSNet

    psnet.ahrq.gov/web-mm/hold-tpa
    July 29, 2020 - Hold the tPA Citation Text: Fagan SC. Hold the tPA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Dow…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49596/psn-pdf
    December 01, 2009 - Round-Trip Service December 1, 2009 McGrath MH. Round-Trip Service. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/round-trip-service The Case A 70-year-old man with a long history of degenerative joint disease was experiencing increased symptoms in his left knee. He was referred by his primary care provid…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49847/psn-pdf
    November 01, 2018 - Written Signout: It Only Works If You Use The Right One November 1, 2018 Lewis K, Rosenbluth G. Written Signout: It Only Works If You Use The Right One. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one The Case A 75-year-old man was hospitalized due to a stro…

  8. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
    January 01, 2021 - Spotlight Spotlight The Consequences of Miscommunication Regarding a Possible Artifact Source and Credits • This presentation is based on the June 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Kriti Gwal, MD o AHRQ WebM&M Edit…

  9. Central, not Epidural | PSNet

    psnet.ahrq.gov/web-mm/central-not-epidural
    August 28, 2024 - Central, not Epidural Citation Text: Simmons D. Central, not Epidural. 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 XML Endnote tagged PubMedI…

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

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.161_slideshow.ppt
    October 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case October 2007 Do Not Disturb! Source and Credits This presentation is based on the October 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available online Commentary by: F. Daniel Duffy, MD, University of Oklahoma, and…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49704/psn-pdf
    March 01, 2014 - Late Anemia Following Rh Disease in a Newborn March 1, 2014 Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn The Case A full-term neonate was delivered uneventfully to an Rh-negative woman who had re…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49599/psn-pdf
    February 23, 2010 - Defensive Medicine: "Glowing" with Pain February 1, 2010 Sethi MK. Defensive Medicine: "Glowing" with Pain. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain The Case   A 31-year-old man presented to the emergency department (ED) complaining of abdominal pain and vomiting. The…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33880/psn-pdf
    May 01, 2019 - Safety in the Prehospital Emergency Medical Services Setting May 1, 2019 Patterson DP, Yealy DM. Safety in the Prehospital Emergency Medical Services Setting. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting Perspective Emergency medical services (E…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49808/psn-pdf
    October 01, 2017 - High-Risk Medications, High-Risk Transfers October 1, 2017 Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers The Case A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853772/psn-pdf
    September 27, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable September 27, 2023 Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable The Case A fourteen-ye…

  16. Putoolssect7 (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressureulcertoolkit/putoolssect7.docx
    February 16, 2011 - Section 7. Tools and Resources 0A: Introductory Executive Summary for Stakeholders 1A: Clinical Staff Attitudes Towards Pressure Ulcer Prevention 1B: Stakeholder Analysis 1C: Leadership Support Assessment 1D: Business Case Form 1E: Resource Needs Assessment 2A: Multidisciplinary Team 2B: Quality Improvement Process 2C…

  17. Detailed Findings | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/findings.html
    August 01, 2022 - whether these reported changes are impacts of the reforms or are related to other changes that might have occurred … and that malpractice suits often fail to identify seven of every eight cases when preventable harm occurred

  18. Final Progress Report: Safety in the Home Healthcare Sector: A Pilot Study (pdf file)

    www.ahrq.gov/sites/default/files/2024-11/gershon-report.pdf
    January 01, 2024 - HHC sector is large, employing over 1.3 million workers in a variety of occupations.22 Most growth occurred … More than half of the back injuries occurred during patient care.

  19. Timely Blood Culture for Children With Sepsis Syndrome (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-229-fullreport.pdf
    February 01, 2018 - was sometimes difficult for abstractors to identify the time at which this 14 event actually occurred … For example, a nurse’s note might state that a blood draw occurred at a given time, but the laboratory

  20. Section 6.B, Validation Studies (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/duration/chipra-156-section-6b.pdf
    January 01, 2013 - follow-up care visits within 10 months after the first prescription of medication for ADHD, one of which occurred … follow-up care visits within 10 months after the first prescription of medication for ADHD, one of which occurred … follow-up care visits within 10 months after the first prescription of medication for ADHD, one of which occurred … follow-up care visits within 10 months after the first prescription of medication for ADHD, one of which occurred … follow-up care visits within 10 months after the first prescription of medication for ADHD, one of which occurred
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