Results

Total Results: 4,038 records

Showing results for "occurring".

1941. Workarounds and Resiliency on the Front Lines of Health Care | PSNet
      psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
      August 01, 2009 - downside of first-order problem solving is lack of communication, which hinders real improvement from occurring … Even this meager form of second-order problem solving was rare, occurring in only 7% of the situations

1942. In Conversation with...Steven J. Spear, DBA, MS, MS | PSNet
      psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
      August 01, 2009 - downside of first-order problem solving is lack of communication, which hinders real improvement from occurring … Even this meager form of second-order problem solving was rare, occurring in only 7% of the situations

1943. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865296/psn-pdf
      March 27, 2024 - National Patient Safety Goals March 27, 2024 Shaikh U. National Patient Safety Goals. PSNet [internet]. 2024. https://psnet.ahrq.gov/primer/national-patient-safety-goals Background Despite the development and publication of effective and evidence-based strategies to enhance patient safety and reduce preventable h…

1944. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33574/psn-pdf
      March 15, 2025 - Ambulatory Care Safety March 15, 2025 Ambulatory Care Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/ambulatory-care-safety 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. Las…

1945. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49604/psn-pdf
      June 01, 2010 - Tacit Handover, Overt Mishap June 1, 2010 Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap The Case A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3 years earlier to treat an abdo…

1946. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.140_slideshow.ppt
      December 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case December 2006 Hidden Heparins: HIT Happens Source and Credits This presentation is based on the December 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: Patrick F. Fogarty,…

1947. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49592/psn-pdf
      October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…

1948. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49466/psn-pdf
      October 14, 2004 - Hard to Swallow October 1, 2004 Driver J. Hard to Swallow. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/hard-swallow The Case An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic attack (TIA) and respiratory difficulties. The nurses noted that the patient, …

1949. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49607/psn-pdf
      August 01, 2010 - Missed Patient Assignment: Is Anyone There? August 1, 2010 Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There? PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there The Case In one hospital, nurses' patient assignments were communicated by listing the…

1950. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
      January 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case January 2008 How Do Providers Recover from Errors? Source and Credits This presentation is based on the January 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Colin P. West, MD, PhD, Mayo Clini…

1951. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49452/psn-pdf
      July 01, 2004 - Allergy to Holter July 1, 2004 Williams M. Allergy to Holter. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/allergy-holter The Case A 52-year-old man was admitted for palpitations and chest pain. As part of the evaluation, on hospital day 4 the patient was sent to the cardiac clinic to start a continuous …

1952. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49493/psn-pdf
      November 01, 2005 - Infused, Not Ingested November 1, 2005 Foley M. Infused, Not Ingested. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/infused-not-ingested The Case A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering contrast, an unfamiliar task for this particular nurse. Rathe…

1953. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.317_slideshow.ppt
      March 01, 2014 - PowerPoint Presentation Spotlight Case Tough Call: Addressing Errors From Previous Providers 1 This presentation is based on the March 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: William Martinez, MD, MS, Assistant Professor of Medicine, …

1954. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49784/psn-pdf
      February 01, 2017 - Safeguarding Diagnostic Testing at the Point of Care February 1, 2017 Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care The Case A 23-year-old woman presented to the family medicine clinic for…

1955. Miscommunication in the OR Leads to Anticoagulation Mishap | PSNet
      psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
      May 08, 2019 - Miscommunication in the OR Leads to Anticoagulation Mishap Citation Text: Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Forma…

1956. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49527/psn-pdf
      December 01, 2006 - The Commentary Background Errors in laboratory services encompass a number of problems occurring outside … physicians often attribute to errors inside the laboratory, are actually the result of preanalytic problems occurring … Specific Errors in This Case The particular error in this case is a mislabeling error occurring outside

1957. The Safety and Quality of Long Term Care | PSNet
      psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
      January 01, 2016 - warrants close assessment and aggressive management by nursing staff to prevent serious breakdown from occurring … constitute nearly 10% of Medicare admissions to acute care, with nearly 40% of these hospitalizations occurring … taking high risk medications such as anticoagulants are monitored daily to assure no adverse events are occurring

1958. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49830/psn-pdf
      May 01, 2018 - In a recent study of adverse events occurring on mental health units in the Veterans Health Administration … Adverse events occurring on VHA mental health units. Gen Hosp Psychiatry. 2018;50:63-68.

1959. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33687/psn-pdf
      August 01, 2009 - downside of first-order problem solving is lack of communication, which hinders real improvement from occurring … Even this meager form of second-order problem solving was rare, occurring in only 7% of the situations

1960. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49650/psn-pdf
      March 01, 2012 - The most recent analysis described 46 deaths and 263 procedure-related complications occurring from … references https://psnet.ahrq.gov//#references Quality improvement strategies to prevent these events from occurring