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Showing results for "problems".

  1. The Consequences of Miscommunication Regarding a Possible Artifact | PSNet

    psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
    May 11, 2019 - SPOTLIGHT CASE The Consequences of Miscommunication Regarding a Possible Artifact Citation Text: Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…

  2. Communication Error in a Closed ICU | PSNet

    psnet.ahrq.gov/web-mm/communication-error-closed-icu
    July 01, 2016 - Communication Error in a Closed ICU Citation Text: Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861880/psn-pdf
    January 31, 2024 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes) January 31, 2024 https://psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication- program-reduce-medical Summary Medica…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846769/psn-pdf
    March 29, 2023 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. March 29, 2023 Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue The C…

  5. Delay in Initiating Antibiotics Results in Fatal Error | PSNet

    psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
    August 02, 2015 - SPOTLIGHT CASE Delay in Initiating Antibiotics Results in Fatal Error Citation Text: Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation …

  6. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
    February 26, 2025 - In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis Jessica Behrhorst, MPH, CPPS, CPHRM, CPHQ; Bryan Gale, MA; Cindy Manaoat Van, MHSA, CPPS | February 26, 2025  Also Read the Essay View more articles from the same authors. Citation T…

  7. The Evolution of Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/evolution-root-cause-analysis
    February 26, 2025 - The Evolution of Root Cause Analysis Jessica Behrhorst, MPH, CPPS, CPHRM, CPHQ; Bryan Gale, MA; Cindy Manaoat Van, MHSA, CPPS | February 26, 2025  Also Read the Conversation View more articles from the same authors. Citation Text: Behrhorst J, Gale B, Van CM. Th…

  8. Beyond the Pandemic: Creating Total Systems Safety | PSNet

    psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
    August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD | August 30, 2023  Also Read the Conversation View more articles from the same authors. Citation Text: Van CM, Mossb…

  9. In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety | PSNet

    psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
    August 30, 2023 - In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD | August 30, 2023  Also Read the Essay View more articles from the same authors. …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49666/psn-pdf
    October 01, 2012 - CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure October 1, 2012 Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure Case Objectives Identify risk f…

  11. May I Have Another?—Medication Error | PSNet

    psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
    March 01, 2009 - May I Have Another?—Medication Error Citation Text: Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …

  12. Empiric Steroids: the Good, the Bad, and the Ugly | PSNet

    psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
    June 01, 2015 - SPOTLIGHT CASE Empiric Steroids: the Good, the Bad, and the Ugly Citation Text: Harris ED. Empiric Steroids: the Good, the Bad, and the Ugly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format:…

  13. The Missing Abscess: Radiology Reads in the Digital Era | PSNet

    psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
    January 01, 2009 - SPOTLIGHT CASE The Missing Abscess: Radiology Reads in the Digital Era Citation Text: Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation…

  14. Diagnosing Diagnostic Mistakes | PSNet

    psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
    April 30, 2014 - SPOTLIGHT CASE Diagnosing Diagnostic Mistakes Citation Text: McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google S…

  15. Order Interrupted by Text: Multitasking Mishap | PSNet

    psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
    August 21, 2015 - SPOTLIGHT CASE Order Interrupted by Text: Multitasking Mishap Citation Text: Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: …

  16. The Unfinished Patient Safety Agenda | PSNet

    psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda
    August 01, 2005 - The Unfinished Patient Safety Agenda Linda H. Aiken, PhD, RN | August 1, 2005  Also Read a Conversation View more articles from the same authors. Citation Text: Aiken LH. The Unfinished Patient Safety Agenda. PSNet [internet]. Rockville (MD): Agency for Healthc…

  17. Anticoagulation: Held Too Long | PSNet

    psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
    April 01, 2008 - Anticoagulation: Held Too Long Citation Text: Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…

  18. In Conversation With... John G. Reiling, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd
    June 01, 2014 - In Conversation With... John G. Reiling, PhD December 1, 2012  Citation Text: In Conversation With.. John G. Reiling, PhD. PSNet [internet]. 2012.In Conversation With... John G. Reiling, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49811/psn-pdf
    November 01, 2017 - Delayed Diagnosis of Endocrinologic Emergencies November 1, 2017 Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies The Cases Case #1: A 47-year-old man with a history of hyperthyroidism and h…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33785/psn-pdf
    May 01, 2015 - In Conversation With… John D. Birkmeyer, MD May 1, 2015 In Conversation With… John D. Birkmeyer, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md Editor's note: John D. Birkmeyer, MD, is an internationally recognized health services researcher with expertise in perfo…
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