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Total Results: 4,035 records

Showing results for "occurring".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33612/psn-pdf
    May 01, 2005 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience May 1, 2005 Conway JB, Weingart SN. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/organizat…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49464/psn-pdf
    December 27, 2020 - Lap Burn October 1, 2004 Ball K. Lap Burn. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lap-burn The Case A woman was scheduled for an elective diagnostic laparoscopy for dysfunctional uterine bleeding. After accessing the abdomen with the trocar without complication, the surgeon inserted the laparoscope…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49499/psn-pdf
    December 02, 2020 - An Outpatient 'Zebra' January 1, 2006 Berkowitz L. An Outpatient 'Zebra'. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/outpatient-zebra The Case A 64-year-old man presented to the outpatient clinic with a chief complaint of left foot pain and numbness. His past medical history included lumbar disc diseas…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33817/psn-pdf
    October 01, 2016 - Health Care Data Science for Quality Improvement and Patient Safety October 1, 2016 Rajkomar A. Health Care Data Science for Quality Improvement and Patient Safety. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety Perspective Background Ha…

  5. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.209_slideshow.ppt
    December 01, 2009 - Spotlight Case [MONTH] 2003 Spotlight Case Standard Deviations Source and Credits This presentation is based on the December 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: James E. Sabin, MD Harvard Medical School; Harvard Pilgrim Heal…

  6. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.248_slideshow.ppt
    September 01, 2011 - Spotlight Case July 2008 Spotlight Case The Safety and Quality of Long Term Care * * Source and Credits This presentation is based on the September 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Amy A. Vogelsmeier, PhD, RN, GCNS-BC, Uni…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33777/psn-pdf
    January 01, 2015 - Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care January 1, 2015 Plsek PE. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually…

  8. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.293_slideshow.ppt
    March 01, 2013 - Spotlight Case July 2008 Spotlight Case A Weighty Mistake * * Source and Credits This presentation is based on the March 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Seth J. Bokser, MD, MPH, Associate Professor of Pediatrics & Medical…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33586/psn-pdf
    December 15, 2024 - Alert Fatigue December 15, 2024 Alert Fatigue. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/alert-fatigue 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…

  10. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.434_slideshow.ppt
    February 01, 2018 - PowerPoint Presentation Spotlight Signout Fallout 1 Source and Credits This presentation is based on the February 2018 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH, Harvard M…

  11. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations | PSNet

    psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
    October 27, 2022 - or used on patients” and relevant financial relationships as “financial relationships in any amount occurring

  12. Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet

    psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
    September 24, 2024 - ask, “What were the contributing factors that led to this event, and how can we prevent them from occurring

  13. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety | PSNet

    psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
    December 01, 2012 - SPOTLIGHT CASE "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety Citation Text: Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49831/psn-pdf
    June 01, 2018 - Chest Pain in a Rural Hospital June 1, 2018 MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/chest-pain-rural-hospital Case Objectives Recognize that a significant proportion of the Unites States population receives care in rural safety net emergency dep…

  15. 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…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72589/psn-pdf
    December 23, 2020 - Delayed Breast Cancer Diagnosis: A False Sense of Security. December 23, 2020 Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security The Case A 60-year-old woman was se…

  17. Palliative Care: Comfort vs. Harm | PSNet

    psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
    December 04, 2016 - SPOTLIGHT CASE Palliative Care: Comfort vs. Harm Citation Text: Jox RJ. Palliative Care: Comfort vs. Harm. 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…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49553/psn-pdf
    January 01, 2008 - Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures January 1, 2008 Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures The…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49753/psn-pdf
    February 01, 2016 - Robotic Surgery: Risks vs. Rewards February 1, 2016 Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards Case Objectives Discuss the background and current trends in robotic surgery. Identify the benefits of robotic s…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33873/psn-pdf
    February 01, 2019 - In Conversation With… Susan E. Skochelak, MD, PhD February 1, 2019 In Conversation With… Susan E. Skochelak, MD, PhD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd Editor's note: Dr. Skochelak is the Group Vice President for Medical Education at the American Medica…
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