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Showing results for "occurred".

  1. Health Care Worker Presenteeism: A Challenge for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
    November 03, 2015 - Health Care Worker Presenteeism: A Challenge for Patient Safety Julia E. Szymczak, PhD | October 1, 2017  View more articles from the same authors. Citation Text: Szymczak JE. Health Care Worker Presenteeism: A Challenge for Patient Safety. PSNet [internet]. Rockvi…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49632/psn-pdf
    July 01, 2011 - A Seasonal Care Transition Failure July 1, 2011 Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure The Case A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine resident—for routine follow-up…

  3. Saved by ECMO | PSNet

    psnet.ahrq.gov/web-mm/saved-ecmo
    May 05, 2017 - Saved by ECMO Citation Text: Weiss NA. Saved by ECMO . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49734/psn-pdf
    May 01, 2015 - Departure From Central Line Ritual May 1, 2015 Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/departure-central-line-ritual The Case A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alco…

  5. Point-of-care Mixup: 1 Shot Turns Into 3 | PSNet

    psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
    February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3 Citation Text: Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73335/psn-pdf
    May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition Error May 26, 2021 Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error The Case A 4-year-old (former 33-week premature) boy with a …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72693/psn-pdf
    January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules January 29, 2021 Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules The Case A…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33624/psn-pdf
    December 01, 2005 - In Conversation with…Troyen A. Brennan, MD, JD, MPH December 1, 2005 In Conversation with…Troyen A. Brennan, MD, JD, MPH. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withtroyen-brennan-md-jd-mph Dr. Robert Wachter, Editor, AHRQ WebM&M: What got you interested in the law and its interface…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33772/psn-pdf
    September 01, 2014 - In Conversation With… Rosemary Gibson, MSc September 1, 2014 In Conversation With… Rosemary Gibson, MSc. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc Editor's note: Rosemary Gibson, MSc, is Senior Advisor to The Hastings Center and an editor for JAMA Internal Medicin…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50391/psn-pdf
    September 25, 2019 - Think Like a Surgeon September 25, 2019 Cooper Z. Think Like a Surgeon. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/think-surgeon The Case A patient with a history of T6 paraplegia due to a motor vehicle accident was brought to the emergency department due to delirium. He was found to be hypotensive and…

  11. Design Guide for Implementing Warm Handoffs (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warmhandoff-designguide.pdf
    June 02, 2025 - Design Guide for Implementing Warm Handoffs Design Guide for Implementing Warm Handoffs The Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Table of Contents Introduction ............................................................................................…

  12. Final Revised Operations Center Charter (pdf file)

    digital.ahrq.gov/sites/default/files/OY1%20Operations%20Center%20Charter.pdf
    December 05, 2023 - Final Revised Operations Center Charter Operations Center: Charter – Option Year 1 Agency for Healthcare Research and Quality 5600 Fishers Lane Rockville, MD 20857 www.ahrq.gov Contract No: 75Q80120D00018 Prepared by: NORC at the University of Chicago November 2023 http://www.ahrq.gov/ 1 …

  13. Dangerous Dapsone | PSNet

    psnet.ahrq.gov/web-mm/dangerous-dapsone
    January 10, 2011 - Dangerous Dapsone Citation Text: Bookwalter T. Dangerous Dapsone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…

  14. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-472
    February 26, 2025 - February 26, 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, repor…

  15. Final Revised Operations Center Charter (pdf file)

    cdsic.ahrq.gov/sites/default/files/2024-02/OY1%20Operations%20Center%20Charter.pdf
    January 01, 2024 - Final Revised Operations Center Charter Operations Center: Charter – Option Year 1 Agency for Healthcare Research and Quality 5600 Fishers Lane Rockville, MD 20857 www.ahrq.gov Contract No: 75Q80120D00018 Prepared by: NORC at the University of Chicago November 2023 http://www.ahrq.gov/ 1 …

  16. Delayed Clozapine Prescription in an Elderly Man With Dementia | PSNet

    psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
    August 06, 2014 - Delayed Clozapine Prescription in an Elderly Man With Dementia Citation Text: Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cita…

  17. 6 Tk1 T2-Talking With Residents Family Members Final (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T2-Talking_with_Residents_Family_Members_Final.docx
    October 01, 2016 - Tool 2. Talking With Residents’ Family Members These talking points are presented in Q&A format to encourage an open and respectful dialogue between nurses or prescribing clinicians and residents’ family members about antibiotics and the risks involved with taking antibiotics. The talking points are designed to: (1) ed…

  18. Ventilator-Associated Event Surveillance: Facilitator Guide | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/mvp/modules/vae/surveillance-fac-guide.html
    February 01, 2017 - Ventilator-Associated Event Surveillance: Facilitator Guide AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: Ventilator-Associated Event Surveillance Say: This module will focus on ventilator-associated event surveillance and how it can be used in your unit. Slide 2: Learning Objectiv…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33661/psn-pdf
    December 01, 2007 - Care Transitions December 1, 2007 Kripalani S. Care Transitions. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/care-transitions Perspective Hospital discharge is often viewed as the end of an acute medical event. Goodbyes are said as patients pack their belongings and return home. Physicians scratch …

  20. 6 Tk1 T1-Talking With Residents Final (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T1-Talking_with_Residents_Final.pdf
    October 01, 2016 - Nursing Home Antimicrobial Stewardship Guide Educate & Engage Residents, Family Toolkit To Educate and Engage Residents and Family Members Tool 1. Talking With Residents These talking points are presented in Q&A format to encourage an open and respectful dialogue between nurses or prescribing clinicians and res…
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