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Showing results for "operational".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33603/psn-pdf
    September 15, 2024 - Surgical Site Infections September 15, 2024 Surgical Site Infections. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/surgical-site-infections 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 …
  2. 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…
  3. 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…
  4. 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…
  5. psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
    January 12, 2011 - Team Training: Classroom Training vs. High-Fidelity Simulation Stephen D. Pratt, MD and Benjamin P. Sachs, MB | March 1, 2006  View more articles from the same authors. Citation Text: Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulatio…
  6. psnet.ahrq.gov/web-mm/dropped-lung
    February 06, 2012 - The Dropped Lung Citation Text: Heffner JR. The Dropped Lung. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  7. psnet.ahrq.gov/web-mm/say-it-again
    January 31, 2020 - Say It Again Citation Text: Henriksen K, Hall KK. Say It Again. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  8. psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
    January 29, 2020 - Delayed Diagnosis of Kidney Transplant Complications Citation Text: Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Goo…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49638/psn-pdf
    January 01, 2012 - Communication Failure—Who's in Charge? October 1, 2011 Fackler J, Schwartz JM. Communication Failure—Who's in Charge? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/communication-failure-whos-charge The Case A 20-month-old boy was admitted to the intensive care unit (ICU) following a Fontan surgical procedu…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49495/psn-pdf
    December 01, 2005 - Low on the Totem Pole December 1, 2005 Wachter R. Low on the Totem Pole. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/low-totem-pole Case Objectives Understand the concept of authority gradient List steps that can be taken to increase communication across an authority gradient Consider the current cultu…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33626/psn-pdf
    January 01, 2006 - In Conversation with…Jack Barker, PhD January 1, 2006 In Conversation with…Jack Barker, PhD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withjack-barker-phd Editor's Note: Jack Barker, PhD, is Vice President of Research and Development for Mach One Leadership and a commercial pilot for …
  12. psnet.ahrq.gov/web-mm/abnormal-volunteer-results
    July 18, 2016 - Abnormal Volunteer Results Citation Text: Fernandez C. Abnormal Volunteer Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60652/psn-pdf
    June 29, 2020 - In Conversation With... Anna Legreid Dopp, Pharm. D June 29, 2020 In Conversation With.. Anna Legreid Dopp, Pharm. D. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d Editor’s note: Anna Legreid Dopp, Pharm. D is the Senior Director of Clinical Guidelines and Quality…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33642/psn-pdf
    November 01, 2006 - In Conversation With...Donald A. Norman, PhD November 1, 2006 In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background. How did you become interested…
  15. psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
    May 11, 2014 - Vial Mistakes Involving Heparin Citation Text: Vanderveen T. Vial Mistakes Involving Heparin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49801/psn-pdf
    August 01, 2017 - Despite Clues, Failed to Rescue August 1, 2017 Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue Case Objectives Define failure to rescue. Identify the main contributors to failure-to-rescue events. Appreciate the ongoing areas of scien…
  17. psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd
    February 26, 2025 - In Conversation With… Sidney Dekker, MA, MSc, PhD September 1, 2013  Citation Text: In Conversation With… Sidney Dekker, MA, MSc, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Co…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50613/psn-pdf
    October 30, 2019 - In Conversation With… Neel Shah, MD, MPP October 30, 2019 In Conversation With… Neel Shah, MD, MPP. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-neel-shah-md-mpp Editor's note: Dr. Shah, MD, MPP, is an Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medi…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50841/psn-pdf
    January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near- Miss Wrong Transfusion Event January 29, 2020 Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
  20. psnet.ahrq.gov/web-mm/time-death
    January 03, 2017 - Time of Death? Citation Text: Taekman JM, Wright MC. Time of Death?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

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