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Showing results for "occurring".

2881. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49814/psn-pdf
      December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation Mishap December 1, 2017 Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap The Case A 63-year-old man with a history of coronary…

2882. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49449/psn-pdf
      June 01, 2004 - Lethal Vertigo June 1, 2004 Furman JM. Lethal Vertigo. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lethal-vertigo The Case A 64-year-old woman, with no prior medical history, complained of sudden onset of severe vertigo and vomiting, without headache. Her initial blood pressure in the emergency departme…

2883. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836942/psn-pdf
      April 27, 2022 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room April 27, 2022 Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-m…

2884. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49626/psn-pdf
      May 01, 2011 - Outbreak May 1, 2011 Rothman R, Stapleton S. Outbreak. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/outbreak The Case A 36-year-old healthy man developed an acute febrile illness associated with a vesicular rash. He presented to an urgent care clinic where he was diagnosed with varicella infection ("chic…

2885. PPE
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/infection-prevention/precautions/ppe-precautions.pptx
      March 01, 2017 - PPE Personal Protective Equipment Training Module 3 AHRQ Pub. No. 16(17)-0003-10-EF March 2017 AHRQ Safety Program for Long-Term Care: HAIs/CAUTI AHRQ SAFETY PROGRAM FOR LONG-TERM CARE: HAIs/CAUTI Welcome to today’s training module, titled “Personal Protective Equipment.” This is the third of four training module…

2886. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49414/psn-pdf
      September 01, 2003 - Making Do September 1, 2003 Bradley LD. Making Do. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/making-do The Case A 56-year-old female with dysfunctional uterine bleeding and possible retained intrauterine device (IUD) was scheduled for elective hysteroscopy and dilation and curettage (D&C). Of note, sh…

2887. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49826/psn-pdf
      April 01, 2018 - Air on the Side of Caution April 1, 2018 Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/air-side-caution The Case A young woman with morbid obesity was scheduled for cardiac catheterization to evaluate shortness of breath and chest pain. A decision was m…

2888. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49748/psn-pdf
      December 01, 2015 - Managing Ascites: Hazards of Fluid Removal December 1, 2015 Moore K. Managing Ascites: Hazards of Fluid Removal. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal The Case A 50-year-old man with longstanding alcoholic cirrhosis presented to the emergency department (ED) w…

2889. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49742/psn-pdf
      September 01, 2015 - A Fumbled Handoff to Inpatient Rehab September 1, 2015 Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab The Case An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…

2890. Conceptual Paradigms of Diagnostic Quality, Safety, and Excellence | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology5.html
      April 01, 2025 - Exploration of Foundational Terminology and Paradigms for Improving Diagnosis Conceptual Paradigms of Diagnostic Quality, Safety, and Excellence Previous Page Next Page Table of Contents Exploration of Foundational Terminology and Paradigms for Improving Diagnosis Introduction Perspectives on Di…

2891. Selected Best Practices and Suggestions for Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4i_combo_psi12-dvt-bestpractices.pdf
      May 20, 2016 - Selected Best Practices and Suggestions for Improvement Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety Tool D.4i 1 Selected Best Practices and Suggestions for Improvement PSI 12: Perioperative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT) Why Focus on DVT/PE…

2892. Learning From Defects
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
      April 01, 2025 - Learning From Defects Learning From Defects Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries AHRQ Pub. No. 25-0029 April 2025 AHRQ Safety Program for MRSA Prevention: Targeting SSI AHRQ Safety Program for MRSA Prevention | Surgical Services Learning From Defects 1 Educat…

2893. A systematic review of the psychological literature on interruption and its patient safety implications. | PSNet
      psnet.ahrq.gov/issue/systematic-review-psychological-literature-interruption-and-its-patient-safety-implications
      September 24, 2016 - September 24, 2016 Medication errors occurring with the use of bar-code administration

2894. A patient reported approach to identify medical errors and improve patient safety in the emergency department. | PSNet
      psnet.ahrq.gov/issue/patient-reported-approach-identify-medical-errors-and-improve-patient-safety-emergency
      July 13, 2010 - June 2, 2021 Analysis of risk factors for patient safety events occurring in the emergency

2895. Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative. | PSNet
      psnet.ahrq.gov/issue/characteristics-medication-errors-and-adverse-drug-events-hospitals-participating-california
      July 13, 2010 - October 30, 2010 Medication errors occurring with the use of bar-code administration

2896. Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events in an oncology population. | PSNet
      psnet.ahrq.gov/issue/comparison-voluntary-safety-reporting-system-global-trigger-tool-identifying-adverse-events
      July 24, 2017 - October 16, 2024 Review of reported adverse events occurring among the homeless veteran

2897. A multifaceted approach to safety: the synergistic detection of adverse drug events in adult inpatients. | PSNet
      psnet.ahrq.gov/issue/multifaceted-approach-safety-synergistic-detection-adverse-drug-events-adult-inpatients
      April 11, 2011 - March 10, 2011 Medication errors occurring with the use of bar-code administration technology

2898. Safety of overlapping surgery at a high-volume referral center. | PSNet
      psnet.ahrq.gov/issue/safety-overlapping-surgery-high-volume-referral-center
      January 11, 2017 - August 29, 2012 Classification of adverse events occurring in a surgical intensive care

2899. Finding diagnostic errors in children admitted to the PICU. | PSNet
      psnet.ahrq.gov/issue/finding-diagnostic-errors-children-admitted-picu
      May 21, 2016 - May 18, 2022 Preventable harm occurring to critically ill children.

2900. The effect of visitation restrictions on ED error. | PSNet
      psnet.ahrq.gov/issue/effect-visitation-restrictions-ed-error
      July 01, 2016 - March 2, 2022 Analysis of risk factors for patient safety events occurring in the emergency