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Showing results for "outcome".

9661. In-facility delirium programs as a patient safety strategy: a systematic review. | PSNet
      psnet.ahrq.gov/issue/facility-delirium-programs-patient-safety-strategy-systematic-review
      March 13, 2013 - Review In-facility delirium programs as a patient safety strategy: a systematic review. Citation Text: Reston JT, Schoelles KM. In-facility delirium prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):375-80. doi:10.7326/0003-4819-158…

9662. The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives. | PSNet
      psnet.ahrq.gov/issue/silent-treatment-why-safety-tools-and-checklists-arent-enough-save-lives
      April 03, 2009 - Book/Report Classic The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives. Citation Text: The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives. Maxfield D, Grenny J, Lavandero R, et al. Provo, UT: VitalS…

9663. Ohio Patient Safety Institute. | PSNet
      psnet.ahrq.gov/issue/ohio-patient-safety-institute-opsi
      January 08, 2020 - Multi-use Website Ohio Patient Safety Institute. Citation Text: Ohio Hospital Association, 155 East Broad St, Suite 301, Columbus, OH 43215-3620.  Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin …

9664. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49520/psn-pdf
      September 01, 2006 - DNR in the OR and Afterwards September 1, 2006 Lo B. DNR in the OR and Afterwards. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/dnr-or-and-afterwards The Case An 85-year-old woman with dementia took a mechanical fall at her skilled nursing facility (SNF) and suffered a fractured femur. After initial eval…

9665. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33681/psn-pdf
      March 01, 2009 - The Role of Health Literacy in Patient Safety March 1, 2009 Wolf MS, Bailey SC. The Role of Health Literacy in Patient Safety. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/role-health-literacy-patient-safety Perspective Clear health communication is increasingly recognized as essential for promoting …

9666. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49730/psn-pdf
      April 01, 2015 - Transition to Nowhere April 1, 2015 Farrell TW. Transition to Nowhere. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/transition-nowhere The Case A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension, and chronic kidney disease was admitted to the hospital …

9667. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.284_slideshow.ppt
      November 01, 2012 - Spotlight Case July 2008 Spotlight Case Transfusion Overload 1 2 Source and Credits This presentation is based on the November 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Manish S. Patel, MD, and Jeffrey L. Carson, MD, of UMDNJ−Robert Wood …

9668. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49773/psn-pdf
      July 01, 2016 - Near Miss With Neonate October 1, 2016 Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/near-miss-neonate The Case A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm dates. Early the next morning, intravenous oxy…

9669. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73146/psn-pdf
      April 28, 2021 - Patient Safety in Home Dialysis April 28, 2021 Morfín JA, Fitall E, Hall KK, et al. Patient Safety in Home Dialysis. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/patient-safety-home-dialysis Dialysis Care and Patient Safety Concerns In patients with chronic kidney disease, kidney function declines ov…

9670. Patient Engagement in Safety | PSNet
      psnet.ahrq.gov/perspective/patient-engagement-safety
      January 01, 2018 - Annual Perspective Patient Engagement in Safety Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2017  View more articles from the same authors. Citation Text: Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. Rockville (MD): Agency…

9671. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33761/psn-pdf
      February 01, 2014 - Interruptions and Distractions in Health Care: Improved Safety With Mindfulness February 1, 2014 Beyea SC. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulne…

9672. Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary | PSNet
      psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
      February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL February 26, 2025 Innovation Contact …

9673. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867427/psn-pdf
      December 18, 2024 - The Ongoing Journey to Prevent Patient Falls December 18, 2024 Dykes PC, Sousane Z, Mossburg SE. The Ongoing Journey to Prevent Patient Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls Falls are not a new issue, especially among older adults. The Centers for D…

9674. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866847/psn-pdf
      September 25, 2024 - In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement September 25, 2024 Stockmeier CA, Mossburg S, Lee M. In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Are…

9675. The Soil, Not the Seed: The Real Problem with Root Cause Analysis | PSNet
      psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
      March 01, 2007 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis Patrice Spath, BA, RHIT, and William Minogue, MD | July 1, 2008  View more articles from the same authors. Citation Text: Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause …

9676. Patient Safety Concerns and the LGBTQ Population | PSNet
      psnet.ahrq.gov/perspective/patient-safety-concerns-and-lgbtq-population
      February 01, 2023 - Patient Safety Concerns and the LGBTQ+ Population Connor Wesley, RN, BSN,Cindy Manaoat Van, MHSA,Sarah E. Mossburg, RN, PhD | February 1, 2023  Also Read the Conversation View more articles from the same authors. Citation Text: Wesley C, Van CM, Mossburg S. Pa…

9677. 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 - judgment and errors in technique occurred, and the attending surgeon was ultimately responsible for the outcome … Approach to Improving Patient Safety Errors in both judgement and technique led to this adverse outcome … understandings about the allowable number and location of cannulation attempts, could also have improved the outcome … Following these best practices could have resulted in a much better outcome for the patient in this case

9678. Pregnant With Danger | PSNet
      psnet.ahrq.gov/web-mm/pregnant-danger
      January 12, 2011 - e.g., CT scan) might have detected the aortic dissection before the discharge and subsequent tragic outcome … The mother and fetus in this case suffered a tragic outcome at a hospital that appeared to lack a structured … It is unclear whether the outcome would have been different elsewhere. … Aortic dissection in pregnancy: analysis of risk factors and outcome.

9679. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49546/psn-pdf
      October 17, 2007 - https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references Luckily, this case has a good outcome … student or practicing team level through critical incident root cause analysis and http://www.acgme.org/outcome … Available at: http://www.acgme.org/outcome/. Accessed September 27, 2007. 13. … cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9032162 http://www.acgme.org/outcome/ http://www.ama-assn.org

9680. Effectiveness of Toyota process redesign in reducing thyroid gland fine-needle aspiration error. | PSNet
      psnet.ahrq.gov/issue/effectiveness-toyota-process-redesign-reducing-thyroid-gland-fine-needle-aspiration-error
      June 14, 2011 - June 14, 2011 Frequency and outcome of cervical cancer prevention failures in the United