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Total Results: 4,038 records

Showing results for "occurring".

  1. 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…

  2. 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…

  3. 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…

  4. 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…

  5. 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…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33771/psn-pdf
    August 22, 2014 - Beyond the Hospital: the New Frontier of Patient Safety August 22, 2014 Plews-Ogan M. Beyond the Hospital: the New Frontier of Patient Safety. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety Perspective The frontier of patient safety outside the hospital has y…

  7. 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…

  8. 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…

  9. E-prescribing: E for error? | PSNet

    psnet.ahrq.gov/web-mm/e-prescribing-e-error
    February 03, 2021 - SPOTLIGHT CASE E-prescribing: E for error? Citation Text: Ashton EW. E-prescribing: E for error?. 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 XM…

  10. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? | PSNet

    psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
    March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? Citation Text: Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. C…

  11. Medication Reconciliation: Whose Job Is It? | PSNet

    psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
    May 01, 2018 - SPOTLIGHT CASE Medication Reconciliation: Whose Job Is It? Citation Text: Poon EG. Medication Reconciliation: Whose Job Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Googl…

  12. 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…

  13. Interdisciplinary teamwork | PSNet

    psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
    November 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…

  14. 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 …

  15. 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…

  16. 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…

  17. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
    January 01, 2022 - Spotlight Spotlight Patient Safety Events Involving Opioid Dose Stacking Source and Credits • This presentation is based on the January 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…

  18. Implementing a Fall Prevention Program | PSNet

    psnet.ahrq.gov/perspective/implementing-fall-prevention-program
    November 29, 2023 - Implementing a Fall Prevention Program Frances Healey, RN, PhD | December 1, 2011  View more articles from the same authors. Citation Text: Healey F. Implementing a Fall Prevention Program. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…

  19. Death by PCA | PSNet

    psnet.ahrq.gov/web-mm/death-pca
    January 06, 2017 - Death by PCA Citation Text: Hicks RW. Death by PCA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Dow…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840174/psn-pdf
    August 28, 2024 - Missed CANDOR Implementation Opportunities. November 16, 2022 Schweitzer L. Missed CANDOR Implementation Opportunities. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities The Case A 58-year-old man with a history of type 2 diabetes mellitus, hypertension, morbid obesit…
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