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Total Results: 4,038 records

Showing results for "occurring".

2121. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49497/psn-pdf
      December 01, 2005 - Slippery Slide Into Life December 1, 2005 Halamek LP. Slippery Slide Into Life. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/slippery-slide-life The Case A 25-year-old woman presented to the hospital in labor and at full gestation after receiving uncomplicated prenatal care. A third-year obstetrics and g…

2122. One Bronchoscopy, Two Errors | PSNet
      psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
      December 09, 2020 - One Bronchoscopy, Two Errors Citation Text: Leiten E, Nielsen R. One Bronchoscopy, Two Errors. 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 XM…

2123. The Wrongful Resuscitation | PSNet
      psnet.ahrq.gov/web-mm/wrongful-resuscitation
      October 12, 2012 - The Wrongful Resuscitation Citation Text: Teno JM. The Wrongful Resuscitation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…

2124. Danger in Disruption | PSNet
      psnet.ahrq.gov/web-mm/danger-disruption
      July 29, 2020 - Danger in Disruption Citation Text: Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…

2125. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
      January 01, 2024 - Spotlight Spotlight Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns 1 Source and Credits This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary …

2126. Wrong Turn through Colon: Misplaced PEG | PSNet
      psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
      May 01, 2017 - Wrong Turn through Colon: Misplaced PEG Citation Text: Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. 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…

2127. Crossed Coverage | PSNet
      psnet.ahrq.gov/web-mm/crossed-coverage
      September 01, 2015 - Crossed Coverage Citation Text: Kayser SR. Crossed Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

2128. Hard to Swallow | PSNet
      psnet.ahrq.gov/web-mm/hard-swallow
      April 26, 2023 - Hard to Swallow Citation Text: Driver J. Hard to Swallow. 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 …

2129. Sick and Pregnant | PSNet
      psnet.ahrq.gov/web-mm/sick-and-pregnant
      August 25, 2021 - Sick and Pregnant Citation Text: El-Ibiary S. Sick and Pregnant. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

2130. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33605/psn-pdf
      March 12, 2021 - Medication Administration Errors March 12, 2021 MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. 2021. https://psnet.ahrq.gov/primer/medication-administration-errors Updated in March 2021. Originally published in January 2018 by researchers at the University of California, San Fra…

2131. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846564/psn-pdf
      March 29, 2023 - study showed that a fully implemented CPOE system significantly reduced specific serious and commonly occurring

2132. Technology as a Tool for Improving Patient Safety | PSNet
      psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
      April 26, 2023 - study showed that a fully implemented CPOE system significantly reduced specific serious and commonly occurring

2133. In Conversation with…Eric G. Poon, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
      September 01, 2008 - In Conversation with…Eric G. Poon, MD, MPH September 1, 2008  Also Read an Essay Citation Text: In Conversation with…Eric G. Poon, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…

2134. Spotlight Case September 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.29_slideshow.ppt
      September 01, 2003 - Spotlight Case September 2003 Spotlight Case September 2003 Infant Paralyzed for Intubation Before Airway Materials Ready Source and Credits This presentation is based on the Sept. 2003 AHRQ WebM&M Spotlight Case in Pediatrics See the full article at http://webmm.ahrq.gov CME credit is available through the …

2135. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49559/psn-pdf
      April 01, 2008 - The Forgotten Drip April 1, 2008 Josephson AS. The Forgotten Drip. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/forgotten-drip The Case A 45-year-old man was brought to the emergency department by his friends because of a 1-day history of a severe headache and "bizarre behavior." A computed tomography (C…

2136. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33755/psn-pdf
      September 01, 2013 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety September 1, 2013 Singer SJ. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/what-weve-learned-ab…

2137. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33585/psn-pdf
      March 15, 2025 - Radiation Safety March 15, 2025 Radiation Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/radiation-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. Last reviewed in 2025…

2138. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33641/psn-pdf
      November 01, 2006 - Human Factors Engineering Can Teach You How to Be Surprised Again November 1, 2006 Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Again. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again Perspective Certain phrases ar…

2139. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49460/psn-pdf
      September 01, 2004 - Security Lapse September 1, 2004 Mason D. Security Lapse. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/security-lapse The Case A medical student learned that the hospital's radiology image library was accessible throughout the university's computer system, meaning that patient x-rays could be viewed in d…

2140. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33753/psn-pdf
      August 22, 2013 - Update on Safety Culture August 22, 2013 Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/update-safety-culture Perspective Safe and reliable care requires a culture of safety: a collaborative environment in which skilled clinicians treat each other with r…