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Showing results for "recognized".

2161. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49619/psn-pdf
      February 01, 2011 - Paradoxical Pulse February 1, 2011 Roy CL. Paradoxical Pulse. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/paradoxical-pulse The Case An 80-year-old man with paroxysmal atrial fibrillation and symptomatic bradycardia underwent successful pacemaker placement as an outpatient. The patient was restarted on …

2162. Double Dose at Transfer | PSNet
      psnet.ahrq.gov/web-mm/double-dose-transfer
      November 01, 2012 - Double Dose at Transfer Citation Text: Hackman JL. Double Dose at Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…

2163. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49868/psn-pdf
      July 02, 2019 - Delayed Clozapine Prescription in an Elderly Man With Dementia July 2, 2019 Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia The Case An 86-year-old man with neurode…

2164. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866621/psn-pdf
      August 28, 2024 - Application of Safety-II Principles August 28, 2024 Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/application-safety-ii-principles Traditional approaches to patient safety have often been reactive rather than proactive, seeki…

2165. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49441/psn-pdf
      March 01, 2004 - Fumbled Handoff March 1, 2004 Vidyarthi A. Fumbled Handoff. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/fumbled-handoff The Case A 73-year-old female with history of hypertension, non-insulin dependent diabetes mellitus (NIDDM), and chronic renal insufficiency was admitted for an elective sigmoid resect…

2166. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33679/psn-pdf
      January 01, 2009 - Disclosure of Medical Error January 1, 2009 Kachalia A. Disclosure of Medical Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/disclosure-medical-error Perspective Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts advocate that greater discl…

2167. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49409/psn-pdf
      July 01, 2003 - Feeling No Pain July 1, 2003 Bogner MS. Feeling No Pain. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/feeling-no-pain The Case A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…

2168. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49404/psn-pdf
      June 01, 2003 - Not a Miscarriage June 1, 2003 Learman LA. Not a Miscarriage. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/not-miscarriage The Case A 32-year-old woman, gravida 3, para 1, with a history of Type 2 diabetes mellitus on metformin, presented at 7 and 2/7 weeks by last menstrual period (LMP). The patient rep…

2169. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49420/psn-pdf
      October 01, 2003 - To LP or Not LP October 1, 2003 Landrigan CP. To LP or Not LP. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/lp-or-not-lp The Case A 4-month-old male infant was seen in the office setting of a large multisite practice. He presented with fever and irritability without an obvious source. He was referred to …

2170. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60169/psn-pdf
      March 25, 2020 - Is that solution for IV or irrigation?: Fluid administration errors in the operating room. March 25, 2020 Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-erro…

2171. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49842/psn-pdf
      September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment September 1, 2018 Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment The Case As part of…

2172. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49435/psn-pdf
      February 01, 2004 - X-ray Flip February 1, 2004 Shapiro MJ. X-ray Flip. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/x-ray-flip The Case A 19-year-old man presented to the emergency department with respiratory distress after blunt chest trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…

2173. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
      February 01, 2012 - Spotlight Case July 2008 Spotlight Case E-prescribing: E for Error? 1 2 Source and Credits This presentation is based on the February 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Elisa W. Ashton, PharmD, Assistant Clinical Professor, Departm…

2174. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49867/psn-pdf
      July 02, 2019 - Diuretics and Electrolyte Abnormalities July 2, 2019 Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities Case Objectives Recognize that thiazide diuretics can lead to serious adverse events. State how commonly used t…

2175. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.128_slideshow.ppt
      July 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case July 2006 Moving Pains Source and Credits This presentation is based on the June/July 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Hildy Schell, RN, MS, CCRN, CCNS, and…

2176. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866395/psn-pdf
      July 23, 2024 - Rescue Improvement Conference Innovation Summary July 23, 2024 https://psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary Summary The Rescue Improvement Conference (RIC)1 was designed at the University of Michigan to address failure to rescue with a particular focus on communication and com…

2177. Measuring and Responding to Deaths From Medical Errors | PSNet
      psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
      April 01, 2008 - Annual Perspective Measuring and Responding to Deaths From Medical Errors Sumant Ranji, MD | March 22, 2016  View more articles from the same authors. Citation Text: Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. Rockville…

2178. An Outpatient 'Zebra' | PSNet
      psnet.ahrq.gov/web-mm/outpatient-zebra
      January 23, 2020 - An Outpatient 'Zebra' Citation Text: Berkowitz L. An Outpatient 'Zebra'. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…

2179. Informed or Misled? | PSNet
      psnet.ahrq.gov/web-mm/informed-or-misled
      April 24, 2018 - Informed or Misled? Citation Text: White SM. Informed or Misled? . 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 tagged PubMedId…

2180. Dropping to New Lows | PSNet
      psnet.ahrq.gov/web-mm/dropping-new-lows
      December 18, 2024 - She also recognized multiple problems with the system that were contributing.