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Total Results: 4,035 records

Showing results for "occurring".

3361. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49858/psn-pdf
      April 01, 2019 - What Happened on Telemetry? April 1, 2019 Sandau KE, Funk M. What Happened on Telemetry? PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/what-happened-telemetry Case Objectives Describe current hospital practices for continuous telemetry monitoring. Appreciate key recommendations from the Update to Practice…

3362. Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
      January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx Spotlight Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm…

3363. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33770/psn-pdf
      August 01, 2014 - In Conversation With… Urmimala Sarkar, MD, MPH August 1, 2014 In Conversation With… Urmimala Sarkar, MD, MPH. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph Editor's note: Urmimala Sarkar, MD, MPH, is associate professor of medicine at the University of California, S…

3364. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49771/psn-pdf
      July 01, 2016 - Unintended Consequences of CPOE October 1, 2016 Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe Case Objectives Explain how technology, including computerized provider order entry, can transform, rather than eliminate, hazards. Recogni…

3365. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49834/psn-pdf
      July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety July 1, 2018 Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety Case Objectives Unders…

3366. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33843/psn-pdf
      October 01, 2017 - In Conversation With… Jeffrey Starke, MD October 1, 2017 In Conversation With… Jeffrey Starke, MD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-jeffrey-starke-md Editor's note: Dr. Starke is Professor of Pediatrics–Infectious Disease at Baylor College of Medicine and served as Infection…

3367. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33842/psn-pdf
      January 01, 2018 - Assessing the Safety of Electronic Health Records: What Have We Learned? September 1, 2017 Sittig DF, Singh H. Assessing the Safety of Electronic Health Records: What Have We Learned? PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned Perspec…

3368. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? | PSNet
      psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
      March 31, 2021 - Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? Citation Text: Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…

3369. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33784/psn-pdf
      April 01, 2015 - In Conversation With… David Urbach, MD, MSc April 1, 2015 In Conversation With… David Urbach, MD, MSc. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-david-urbach-md-msc Editor's note: Dr. David Urbach is Professor of Surgery and Health Policy, Management, and Evaluation at the University…

3370. Radiology Missed an Intracranial Bleed in a Lethargic Infant. | PSNet
      psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
      August 21, 2016 - Radiology Missed an Intracranial Bleed in a Lethargic Infant. Citation Text: Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation For…

3371. Peripheral IV in Too Long | PSNet
      psnet.ahrq.gov/web-mm/peripheral-iv-too-long
      September 15, 2011 - SPOTLIGHT CASE Peripheral IV in Too Long Citation Text: Fang C-T. Peripheral IV in Too Long. 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 X3 XML End…

3372. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49810/psn-pdf
      November 01, 2017 - Palliative Care: Comfort vs. Harm November 1, 2017 Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm Case Objectives Recognize errors may be difficult to identify in palliative care. State that medication errors and errors in communica…

3373. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest | PSNet
      psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
      April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest Citation Text: Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. Rockvil…

3374. Interdisciplinary teamwork | PSNet
      psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
      August 10, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Interdisciplinary teamwork  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet T…

3375. Missed CANDOR Implementation Opportunities. | PSNet
      psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
      November 11, 2020 - Missed CANDOR Implementation Opportunities. Citation Text: Schweitzer L. Missed CANDOR Implementation Opportunities.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX EndN…

3376. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia | PSNet
      psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
      January 29, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia Citation Text: Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and…

3377. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout | PSNet
      psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
      January 22, 2020 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout Citation Text: Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …

3378. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. | PSNet
      psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
      January 29, 2021 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. Citation Text: Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.. PSNet [internet]. Rockville (MD): Ag…

3379. Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors | PSNet
      psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
      May 31, 2023 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL March 3, 2021 Innovation…

3380. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49790/psn-pdf
      April 01, 2017 - Patient Allergies and Electronic Health Records April 1, 2017 Doyle MJ. Patient Allergies and Electronic Health Records. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records The Case A 40-year-old woman presented with recurring intense right upper quadrant pain, whi…