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Total Results: 4,038 records

Showing results for "occurring".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33636/psn-pdf
    July 01, 2006 - Key Issues in Developing a Successful Hospital Safety Program July 1, 2006 Whittington JC. Key Issues in Developing a Successful Hospital Safety Program. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program Perspective What are the key success factors…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33606/psn-pdf
    December 15, 2024 - Opioid Safety December 15, 2024 Opioid Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/opioid-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 2024. Bac…

  3. High Reliability | PSNet

    psnet.ahrq.gov/primer/high-reliability
    January 29, 2020 - High Reliability Citation Text: High Reliability. 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 XML Endnote tagged PubMedId RIS Downl…

  4. Human Factors Engineering | PSNet

    psnet.ahrq.gov/primer/human-factors-engineering
    December 15, 2024 - Human Factors Engineering Citation Text: Human Factors Engineering. 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 XML Endnote tagged PubMedId R…

  5. PSNet Curated Library (pdf file)

    psnet.ahrq.gov/print/pdf/node/842920
    December 14, 2022 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Diagnostic Errors Case Studies Curated Library Web M&Ms A Postpartum Woman with an Erroneous SARS-CoV-2 Test Stephen A. Martin, MD, EdM, Gordon D. Schiff, MD, and Sanjat Kanjilal, MD, MPH | April 28, 2021 A pregnant patient was admitted for…

  6. Update: Patient Engagement in Safety | PSNet

    psnet.ahrq.gov/perspective/update-patient-engagement-safety
    January 01, 2017 - Annual Perspective Update: Patient Engagement in Safety Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2018  View more articles from the same authors. Citation Text: Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. Rockvi…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33872/psn-pdf
    January 01, 2018 - Update: Patient Engagement in Safety January 1, 2018 Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/update-patient-engagement-safety Annual Perspective 2018 Background Patient engagement has become a cornerstone of patient safety. A Patient Saf…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49658/psn-pdf
    July 01, 2012 - Misleading Complaint July 1, 2012 Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/misleading-complaint The Case A 54-year-old homeless man with a history of alcoholism presented to the emergency department (ED) with complaints of knee problems. The triage nurse docu…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33708/psn-pdf
    March 01, 2011 - So there is a handoff occurring at discharge, and I often think just like you would communicate and

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33692/psn-pdf
    February 01, 2010 - Handoffs are occurring at multiple levels in the system at the same time.

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866261/psn-pdf
    July 10, 2024 - Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery July 10, 2024 Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/missed-compartment-syndrome…

  12. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
    January 01, 2024 - Spotlight Spotlight Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Christian Bohringer, MBBS, …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49483/psn-pdf
    June 01, 2005 - Getting to the Root of the Matter June 1, 2005 Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/getting-root-matter Case Objectives Appreciate the goals and limitations of root cause analysis Outline the steps to conduct root cause analysis The Case A…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60542/psn-pdf
    May 27, 2020 - Life-Threatening Infant Overdose of Sodium Chloride May 27, 2020 Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride The Case  An infant with trisomy 21 underwent repair of a…

  15. Difficult Encounters: A CMO and CNO Respond | PSNet

    psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
    March 01, 2018 - SPOTLIGHT CASE Difficult Encounters: A CMO and CNO Respond Citation Text: Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: …

  16. Syringe Swap During Regional Block: A Case of Medication Error and Recovery | PSNet

    psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
    July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery Citation Text: Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…

  17. In Conversation With... Jeffrey Shuren, MD, JD | PSNet

    psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd
    May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD May 28, 2020  Also Read the Essay Citation Text: In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020.In Conversation With... Jeffrey Shuren, MD, JD. PSNet [internet]. Rockville (MD): Agency for Healt…

  18. Despite Clues, Failed to Rescue | PSNet

    psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
    August 02, 2015 - SPOTLIGHT CASE Despite Clues, Failed to Rescue Citation Text: Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndN…

  19. Getting to the Root of the Matter | PSNet

    psnet.ahrq.gov/web-mm/getting-root-matter
    September 01, 2005 - SPOTLIGHT CASE Getting to the Root of the Matter Citation Text: Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Schola…

  20. The Deadly Duo | PSNet

    psnet.ahrq.gov/web-mm/deadly-duo
    April 28, 2021 - The Deadly Duo Citation Text: Maldonado JR. The Deadly Duo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
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