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Showing results for "occurring".

2021. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851555/psn-pdf
      July 31, 2023 - Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation July 31, 2023 Flynn S, Barnes DK. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation The Case A 56-year-…

2022. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50612/psn-pdf
      October 30, 2019 - The Safety Challenges of Supervision and Night Coverage in Academic Residency October 30, 2019 Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency The Case…

2023. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49529/psn-pdf
      February 01, 2007 - Crossed Coverage February 1, 2007 Kayser SR. Crossed Coverage. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/crossed-coverage The Case A 27-year-old woman with a history of congenital heart disease was admitted for cardiac transplantation evaluation. She had already undergone multiple surgeries, including…

2024. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49728/psn-pdf
      March 01, 2015 - Medication Mix-Up: From Bad to Worse March 1, 2015 Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/medication-mix-bad-worse The Case A 69-year-old man with chronic kidney disease and essential hypertension was admitted to the hospital with chest …

2025. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49662/psn-pdf
      August 01, 2012 - Wrong Turn through Colon: Misplaced PEG August 1, 2012 Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg The Case An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…

2026. Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner | PSNet
      psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
      February 26, 2025 - Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL A…

2027. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49665/psn-pdf
      September 01, 2012 - Undetected Foreign Object September 1, 2012 Cima RR. Undetected Foreign Object. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/undetected-foreign-object The Case A 75-year-old man with a past medical history of end-stage renal disease (on hemodialysis), hypertension, and diabetes was found to have obstruct…

2028. The 2-Week Itch | PSNet
      psnet.ahrq.gov/web-mm/2-week-itch
      June 16, 2019 - The 2-Week Itch Citation Text: Cohen MR. The 2-Week Itch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

2029. Inpatient Transitions of Care: Challenges and Safety Practices | PSNet
      psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
      June 15, 2024 - Inpatient Transitions of Care: Challenges and Safety Practices Citation Text: Satake A, McElroy V. Inpatient Transitions of Care: Challenges and Safety Practices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation …

2030. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. | PSNet
      psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
      October 27, 2021 - Local Anesthesia-Induced Coma During Total Knee Arthroplasty. Citation Text: Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format…

2031. 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

2032. 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.

2033. 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

2034. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49801/psn-pdf
      August 01, 2017 - Despite Clues, Failed to Rescue August 1, 2017 Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue Case Objectives Define failure to rescue. Identify the main contributors to failure-to-rescue events. Appreciate the ongoing areas of scien…

2035. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49611/psn-pdf
      October 01, 2010 - The Deadly Duo October 1, 2010 Maldonado JR. The Deadly Duo. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/deadly-duo The Case A 29-year-old man with a history of depression and possible psychosis was found unconscious and unresponsive at home and was brought to the emergency department. He was tachycardi…

2036. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861760/psn-pdf
      January 31, 2024 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery January 31, 2024 Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…

2037. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
      January 01, 2022 - Spotlight Spotlight Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong Source and Credits • This presentation is based on the October 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary…

2038. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49591/psn-pdf
      October 01, 2009 - Difficult Encounters: A CMO and CNO Respond October 1, 2009 Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond Case Objectives Appreciate the risk of disruptive behavior and understand institutional respons…

2039. Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle | PSNet
      psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
      July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 29, 2024 View more articles from the same authors. Inno…

2040. Right Patient, Wrong Sample | PSNet
      psnet.ahrq.gov/web-mm/right-patient-wrong-sample
      June 01, 2004 - The Commentary Background Errors in laboratory services encompass a number of problems occurring outside … 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