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Showing results for "organizations".

  1. Good Night's Sleep Gone Wrong | PSNet

    psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
    September 01, 2015 - Good Night's Sleep Gone Wrong Citation Text: Gillis CM, Degrado J, Anger KE. Good Night's Sleep Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49562/psn-pdf
    May 01, 2008 - The Inside of a Time Out May 1, 2008 Feldman DL. The Inside of a Time Out. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/inside-time-out The Case A 65-year-old man was scheduled for an elective endovascular repair of an abdominal aortic aneurysm. The patient had an allergy to "IV contrast dye" that was no…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49398/psn-pdf
    May 01, 2003 - Bloody BP Cuff May 1, 2003 Madan AK. Bloody BP Cuff. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/bloody-bp-cuff The Case Patient #1, a 28-year-old male, was a trauma patient following a motor vehicle collision into a cement pillar. Patient #1 was in the trauma bay with massive injuries and profuse bleed…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49665/psn-pdf
    September 01, 2012 - Undetected Foreign Object September 1, 2012 Cima RR. Undetected Foreign Object. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/undetected-foreign-object The Case A 75-year-old man with a past medical history of end-stage renal disease (on hemodialysis), hypertension, and diabetes was found to have obstruct…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49662/psn-pdf
    August 01, 2012 - Wrong Turn through Colon: Misplaced PEG August 1, 2012 Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg The Case An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49706/psn-pdf
    January 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue April 1, 2014 Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue The Case A 24-year-old wom…

  7. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
    May 01, 2012 - States hospitals.( 1 ) In response to these disturbing data, accreditation bodies, payers, nonprofit organizations … And, we found voluntary reporting picked up no adverse events at that organization.

  8. In Conversation With…David C. Classen, MD, MS | PSNet

    psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
    May 01, 2012 - And, we found voluntary reporting picked up no adverse events at that organization. … States hospitals.( 1 ) In response to these disturbing data, accreditation bodies, payers, nonprofit organizations

  9. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome | PSNet

    psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
    April 27, 2022 - SPOTLIGHT CASE Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome Citation Text: Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome. PSNet [internet…

  10. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication | PSNet

    psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
    August 01, 2012 - SPOTLIGHT CASE The Risks of a Malpositioned Gastrostomy Tube and Poor Communication Citation Text: Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…

  11. Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx Spotlight The Risks of a Malpositioned Gastrostomy Tube and Poor Communication Source and Credits • This presentation is based on the November 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahr…

  12. In Conversation with…Vineet Arora, MD, MA | PSNet

    psnet.ahrq.gov/perspective/conversation-withvineet-arora-md-ma
    March 01, 2011 - In Conversation with…Vineet Arora, MD, MA March 1, 2011  Also Read an Essay Citation Text: In Conversation with…Vineet Arora, MD, MA . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. …

  13. In Conversation With... James Augustine, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-james-augustine-md
    July 28, 2021 - Simultaneously, policymakers and individual EMS organizations are considering the expansion of EMS’ role

  14. Health Equity and Maternal Health | PSNet

    psnet.ahrq.gov/perspective/health-equity-and-maternal-health
    October 06, 2021 - Perspective Patient Safety Events and the Role of Patient Safety Organizations

  15. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
    January 01, 2021 - – The data in PDMPs are state-specific and various settings/organizations in addition to hospitals

  16. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-282
    March 15, 2021 - Newspaper/Magazine Article A recurring call to action: every healthcare organization

  17. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-404
    August 30, 2023 - family’s effort to demonstrate the role of discrimination in the outcome and hold the clinicians and organization

  18. Nursing and Patient Safety | PSNet

    psnet.ahrq.gov/primer/nursing-and-patient-safety
    September 15, 2024 - This rating system gives each organization (e.g., hospital or nursing home) a star score from 1 to 5

  19. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. | PSNet

    psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
    June 28, 2023 - Brentwood (TN): Organization of Teratology Information Specialists (OTIS); 1994-.

  20. Order Interrupted by Text: Multitasking Mishap | PSNet

    psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
    August 21, 2015 - Health Electronic Data Interchange Network (NEHEN) CEO of MA-SHARE (the Regional Health Information Organization
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