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Showing results for "processes".

6081. In Conversation With… Urmimala Sarkar, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
      August 22, 2014 - From these processes we would begin to identify those events in outpatient care that will drive universal

6082. Beyond the Hospital: the New Frontier of Patient Safety | PSNet
      psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
      August 01, 2014 - From these processes we would begin to identify those events in outpatient care that will drive universal

6083. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49764/psn-pdf
      June 01, 2016 - Communication With Consultants June 1, 2016 Cohn SL. Communication With Consultants. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/communication-consultants The Case A 30-year-old pregnant woman presented to the emergency department (ED) with nausea, headaches, and fevers. Her laboratory studies were nota…

6084. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
      April 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Bad Writing, Wrong Medication * * Source and Credits This presentation is based on the April 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Beth Devine, PharmD, MBA, PhD University of Washingto…

6085. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.434_slideshow.ppt
      February 01, 2018 - PowerPoint Presentation Spotlight Signout Fallout 1 Source and Credits This presentation is based on the February 2018 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH, Harvard M…

6086. CE/MOC Quizzes | PSNet
      psnet.ahrq.gov/cme
      February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations A man with a history of prior umbilical hernia repair presented to the emergency department (ED) with abdominal pain and was initially diagnosed with cholelithiasis before being discharged home. However, the next day he returned to …

6087. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33777/psn-pdf
      January 01, 2015 - Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care January 1, 2015 Plsek PE. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually…

6088. 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 …

6089. Root Cause Analysis | PSNet
      psnet.ahrq.gov/primer/root-cause-analysis
      March 30, 2022 - Root Cause Analysis Citation Text: Root Cause Analysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

6090. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33784/psn-pdf
      April 01, 2015 - These perioperative processes were probably being done very frequently.

6091. 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…

6092. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33649/psn-pdf
      May 01, 2007 - In Conversation with...Sir Liam Donaldson, MD, MSc May 1, 2007 In Conversation with..Sir Liam Donaldson, MD, MSc. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc Editor's Note: Sir Liam Donaldson, MD, MSc, is England's Chief Medical Officer, a post often referre…

6093. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49833/psn-pdf
      June 01, 2018 - Perils in Diagnosing a Stroke June 1, 2018 Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/perils-diagnosing-stroke The Case A 75-year-old man with a history of hypertension, diabetes, chronic back pain, and opioid use disorder was brought to the emergency depart…

6094. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49856/psn-pdf
      March 01, 2019 - Premature Extubation March 1, 2019 Sagana R, Hyzy RC. Premature Extubation. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/premature-extubation The Case A 73-year-old woman with a history of carotid artery stenosis was admitted for an elective carotid endarterectomy. The procedure was initially thought to …

6095. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49778/psn-pdf
      December 01, 2016 - One Dose, Two Errors December 1, 2016 Filice GA. One Dose, Two Errors. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/one-dose-two-errors The Case A 65-year-old woman was admitted to the intensive care unit (ICU) with severe sepsis and respiratory failure secondary to community-acquired pneumonia. The pati…

6096. The Physical Environment: An Often Unconsidered Patient Safety Tool | PSNet
      psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
      November 21, 2018 - The Physical Environment: An Often Unconsidered Patient Safety Tool Anjali Joseph, PhD, EDAC; Eileen B. Malone, RN, MSN, MS, EDAC | October 1, 2012  View more articles from the same authors. Citation Text: Joseph A, Malone EB. The Physical Environment: An Often Unc…

6097. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73229/psn-pdf
      May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities May 26, 2021 Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…

6098. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49512/psn-pdf
      May 01, 2006 - Right? Left? Neither! May 1, 2006 Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/right-left-neither Case Objectives Appreciate the role of Reason's Swiss Cheese Model in medical errors Understand the process of analyzing a single error Provide suggestions for …

6099. In Conversation With... Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md
      May 14, 2020 - NS : You need to have processes and procedures in place to manage registration for patients who are not … Such virtual triage processes can protect other patients by directing potentially infected individuals

6100. In Conversation With… Amy C. Edmondson, PhD, AM | PSNet
      psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
      February 01, 2017 - At the same time, there are also many processes that can be (and increasingly are being) standardized … was stunning to me to discover say in the early 1990s how much unnecessary variety I found in work processes